Healthcare Provider Details

I. General information

NPI: 1437254430
Provider Name (Legal Business Name): DAVID JOSEPH BARNEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6690 CROSSINGS DR SE STE C
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

6690 CROSSINGS DR SE STE C
GRAND RAPIDS MI
49508-7394
US

V. Phone/Fax

Practice location:
  • Phone: 616-600-1885
  • Fax:
Mailing address:
  • Phone: 616-600-1885
  • Fax: 616-600-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601004082
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: