Healthcare Provider Details

I. General information

NPI: 1144768656
Provider Name (Legal Business Name): MEGAN SYTSMA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN KOOIMA PA-C

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5270
  • Fax: 616-455-5460
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: