Healthcare Provider Details

I. General information

NPI: 1225193253
Provider Name (Legal Business Name): VALERI A. RUSCO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VALERI A. MARTIN

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MICHIGAN ST NE SUITE 300
GRAND RAPIDS MI
49503-2550
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax:
Mailing address:
  • Phone: 616-459-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601004845
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: