Provider Demographics
NPI:1285968263
Name:LESTER, MARK E (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:LESTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8333 FELCH ST
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464
Practice Address - Country:US
Practice Address - Phone:616-772-4644
Practice Address - Fax:616-748-2828
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005641363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM56180025Medicare PIN
MIM24320019Medicare PIN
MI0M74460 639Medicare PIN