Healthcare Provider Details

I. General information

NPI: 1083595268
Provider Name (Legal Business Name): SAMANTHA LEE EMERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 EAGLE PARK DR NE
GRAND RAPIDS MI
49525-7007
US

IV. Provider business mailing address

3230 EAGLE PARK DR NE
GRAND RAPIDS MI
49525-7007
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-2229
  • Fax: 616-988-2010
Mailing address:
  • Phone: 616-988-2229
  • Fax: 616-988-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: