Healthcare Provider Details

I. General information

NPI: 1326715202
Provider Name (Legal Business Name): SHANA GOETTING BROXUP PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 EAGLE PARK DR NE STE 100
GRAND RAPIDS MI
49525-7047
US

IV. Provider business mailing address

8550 MOUNTAIN PINE LN
KALAMAZOO MI
49009-4992
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-2229
  • Fax: 616-988-2010
Mailing address:
  • Phone: 517-896-9426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010535TMP21
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: