Healthcare Provider Details

I. General information

NPI: 1336515584
Provider Name (Legal Business Name): KERRI CLAUSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4300
US

IV. Provider business mailing address

1310 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4300
US

V. Phone/Fax

Practice location:
  • Phone: 217-260-5794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000123
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: