Healthcare Provider Details

I. General information

NPI: 1306395322
Provider Name (Legal Business Name): THERESE LUNGARO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 N WELLNESS DR BLDG B
HOLLAND MI
49424-8027
US

IV. Provider business mailing address

3232 N WELLNESS DR BLDG B
HOLLAND MI
49424-8027
US

V. Phone/Fax

Practice location:
  • Phone: 616-494-4250
  • Fax: 616-494-4261
Mailing address:
  • Phone: 616-494-4250
  • Fax: 616-494-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: