Healthcare Provider Details

I. General information

NPI: 1750399986
Provider Name (Legal Business Name): KENNETH VANSUMEREN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W WACKERLY ST
MIDLAND MI
48640-2761
US

IV. Provider business mailing address

301 W WACKERLY ST
MIDLAND MI
48640-2761
US

V. Phone/Fax

Practice location:
  • Phone: 989-832-0900
  • Fax: 989-633-0349
Mailing address:
  • Phone: 989-832-0900
  • Fax: 989-633-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003931
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: