Healthcare Provider Details

I. General information

NPI: 1871532176
Provider Name (Legal Business Name): LISA GARWOOD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 CASCADE RD SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-1500
  • Fax: 616-252-1599
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003132
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: