Healthcare Provider Details

I. General information

NPI: 1104119288
Provider Name (Legal Business Name): AUSTIN NELSON KUIPERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRANDVILLE AVE SW
GRAND RAPIDS MI
49503-4920
US

IV. Provider business mailing address

245 STATE ST SE STE 228
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8400
  • Fax: 616-742-1322
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: