Healthcare Provider Details

I. General information

NPI: 1093861593
Provider Name (Legal Business Name): CARL E PIERSMA P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 03/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11315 EDGEWATER DR
ALLENDALE MI
49401-9396
US

IV. Provider business mailing address

11315 EDGEWATER DR
ALLENDALE MI
49401-9396
US

V. Phone/Fax

Practice location:
  • Phone: 616-895-2000
  • Fax: 616-895-2009
Mailing address:
  • Phone: 616-895-2000
  • Fax: 616-895-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002680
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: