Healthcare Provider Details

I. General information

NPI: 1134774524
Provider Name (Legal Business Name): ANTONIO RICHARD BARRON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 LEONARD ST NE
GRAND RAPIDS MI
49505-6438
US

IV. Provider business mailing address

1618 LEONARD ST NE
GRAND RAPIDS MI
49505-6438
US

V. Phone/Fax

Practice location:
  • Phone: 616-591-5995
  • Fax: 616-591-5996
Mailing address:
  • Phone: 989-284-9478
  • Fax: 616-591-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601009203
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: