Healthcare Provider Details

I. General information

NPI: 1609639715
Provider Name (Legal Business Name): ALLISON ANNE MATTHEWS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. ALLISON ANNE RYAN

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax:
Mailing address:
  • Phone: 616-942-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012282
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: