Healthcare Provider Details

I. General information

NPI: 1164248142
Provider Name (Legal Business Name): MASON J VREDEVELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MICHIGAN ST NE
GRAND RAPIDS MI
49503-3314
US

IV. Provider business mailing address

1 CAMPUS DR
ALLENDALE MI
49401-9403
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-5700
  • Fax:
Mailing address:
  • Phone: 616-331-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: