Healthcare Provider Details

I. General information

NPI: 1033190285
Provider Name (Legal Business Name): CARRIE J JEROW MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 LAFAYETTE AVE SE STE 301
GRAND RAPIDS MI
49503-4693
US

IV. Provider business mailing address

310 LAFAYETTE AVE SE STE 301
GRAND RAPIDS MI
49503-4693
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-7850
  • Fax: 616-685-7830
Mailing address:
  • Phone: 616-685-7850
  • Fax: 616-685-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003623
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: