Provider Demographics
NPI:1396708533
Name:STIBITZ, ELLEN JO (PA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:JO
Last Name:STIBITZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:JO
Other - Last Name:VANDERLAAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 S GETTY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1207
Mailing Address - Country:US
Mailing Address - Phone:231-739-9315
Mailing Address - Fax:231-737-1808
Practice Address - Street 1:2201 S GETTY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-739-9315
Practice Address - Fax:231-737-1808
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P57202Medicare UPIN
MI231858Medicare Oscar/Certification