Healthcare Provider Details

I. General information

NPI: 1740488683
Provider Name (Legal Business Name): LEONCIE MUKARURINDA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 WEALTHY ST SE STE 100
GRAND RAPIDS MI
49503-5229
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 616-840-8719
  • Fax: 616-870-9637
Mailing address:
  • Phone: 616-840-8719
  • Fax: 616-840-9637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: