Provider Demographics
NPI:1851594501
Name:PEBBLES, THERESA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:JEAN
Last Name:PEBBLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JEAN
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:1445 SHELDON RD
Practice Address - Street 2:STE 300
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2479
Practice Address - Country:US
Practice Address - Phone:616-296-1500
Practice Address - Fax:616-296-1502
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N48650051Medicare PIN