Healthcare Provider Details

I. General information

NPI: 1710551346
Provider Name (Legal Business Name): ANGELA LYNN CUCKOVICH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA LYNN RITTER PA-C

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3139
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: