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NPI Code Detail

MEDICARE: EASTON IZAAK MANN PA-C

MEDICARE: EASTON IZAAK MANN PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant5601009831MI

General Provider Information

NPI Number : 1447719182
Entity Type Code : Individual
Provider Name (Legal Business Name) : EASTON IZAAK MANN PA-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE # MC845
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4600 BRETON RD SE STE 102
Second Line :
City : KENTWOOD
State : MI
Zip : 49508-5220
Country : US
Telephone Number : 616-391-9700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/12/2019
Last Update Date : 10/03/2023

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