Provider Demographics
NPI:1386072825
Name:ABBOTT, STEPHANIE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 3 MILE RD NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8229
Mailing Address - Country:US
Mailing Address - Phone:616-647-3770
Mailing Address - Fax:616-647-3776
Practice Address - Street 1:721 3 MILE RD NW
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8229
Practice Address - Country:US
Practice Address - Phone:616-647-3770
Practice Address - Fax:616-647-3776
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006779OtherBLUE CROSS BLUE SHIELD