Provider Demographics
NPI:1962602862
Name:BERENT, FARAH N (PA)
Entity type:Individual
Prefix:
First Name:FARAH
Middle Name:N
Last Name:BERENT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:FARAH
Other - Middle Name:N
Other - Last Name:AHMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4085 BURTON ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4918
Practice Address - Country:US
Practice Address - Phone:616-546-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant