Healthcare Provider Details

I. General information

NPI: 1932202058
Provider Name (Legal Business Name): ELLYN KEUR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 11/30/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2332 ALPINE AVE NW
GRAND RAPIDS MI
49544-1955
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845 ATTN JULIE L
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-6220
  • Fax:
Mailing address:
  • Phone: 616-486-6772
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001633
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: