Healthcare Provider Details

I. General information

NPI: 1902805104
Provider Name (Legal Business Name): STEPHEN PAUL DUCHEMIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NW
GRAND RAPIDS MI
49504-3760
US

IV. Provider business mailing address

5340 CHRISTIE AVE SE
KENTWOOD MI
49508-6163
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-1515
  • Fax: 616-224-2070
Mailing address:
  • Phone: 616-455-7849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601001567
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: