Healthcare Provider Details

I. General information

NPI: 1053694976
Provider Name (Legal Business Name): JASON DIPMAN AA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

3333 EVERGREEN DR NE
GRAND RAPIDS MI
49525-9493
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-4200
  • Fax:
Mailing address:
  • Phone: 616-284-3132
  • Fax: 616-284-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number1227
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2011032475
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: