Healthcare Provider Details

I. General information

NPI: 1013461581
Provider Name (Legal Business Name): AUTUMN ELIZABETH DITTENBER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AUTUMN ELIZABETH DEGROAT

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W OAK ST
FREMONT MI
49412-1526
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-924-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007826
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: