Healthcare Provider Details

I. General information

NPI: 1194758037
Provider Name (Legal Business Name): SUSAN LANCE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN THOMPSON PAC

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14211 WHITE CREEK AVE NE
CEDAR SPRINGS MI
49319-8168
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW ATTN: MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-6320
  • Fax: 616-252-6360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: