Provider Demographics
NPI:1699712059
Name:VROEGOP, TODD (PA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:VROEGOP
Suffix:
Gender:M
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 1:2060 E PARIS AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6113
Mailing Address - Country:US
Mailing Address - Phone:616-956-6100
Mailing Address - Fax:616-956-6637
Practice Address - Street 1:2060 E PARIS AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-956-6100
Practice Address - Fax:616-956-6400
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38550021Medicare ID - Type Unspecified
P37545Medicare UPIN