Basic Information
| Provider Information | |||||||||
| NPI: | 1831521608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FERGUSON | ||||||||
| OtherFirstName: | DIANE LESLIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4260 PLYMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481092700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347646831 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704191140 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 487020310 | 05 | MI | MEDICAID |