Healthcare Provider Details

I. General information

NPI: 1083122790
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL BOUMA DNP, AGPCNP-BC, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
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: 616-455-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704272878
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: