Healthcare Provider Details

I. General information

NPI: 1013615749
Provider Name (Legal Business Name): MARISA LYNN ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 E PARKDALE AVE
MANISTEE MI
49660-9709
US

IV. Provider business mailing address

4100 EMBASSY DR SE STE 400
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-8220
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: