Registry details
Type
Individual
Primary specialty
Physician Assistant
Enumerated
Jan 18, 2007
License(s)
5601004208 (MI)
Addresses on file
| Purpose | Address | City/State | Phone |
|---|---|---|---|
| LOCATION | 3304 COOLEY CT | Portage, MI 49024-7430 | 269-349-2266 |
| MAILING | 3264 N EVERGREEN DR NE | Grand Rapids, MI 49525-9746 | 616-363-7339 |
Watch this provider
Get a webhook/email the day this provider is added to the OIG-LEIE exclusion list or appears in an FDA enforcement action.