Healthcare Provider Details

I. General information

NPI: 1477049518
Provider Name (Legal Business Name): MARK CONTRERAS AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

IV. Provider business mailing address

1211 LAFAYETTE AVE NE
GRAND RAPIDS MI
49505-5092
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-8800
  • Fax: 616-331-9831
Mailing address:
  • Phone: 616-336-8800
  • Fax: 616-331-9831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704283879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: