Healthcare Provider Details

I. General information

NPI: 1912936378
Provider Name (Legal Business Name): ELIZABETH ANN HEYBOER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHERRY ST SE STE 2200
GRAND RAPIDS MI
49503-4608
US

IV. Provider business mailing address

5800 FOREMOST DR SE STE 300
GRAND RAPIDS MI
49546-7062
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5600
  • Fax: 616-685-6745
Mailing address:
  • Phone: 616-954-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003823
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: