Healthcare Provider Details

I. General information

NPI: 1134529993
Provider Name (Legal Business Name): MEGAN MOUSER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7686 GEORGETOWN CENTER DR
JENISON MI
49428-8101
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-252-8600
  • Fax: 616-252-8660
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704257340
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: