Healthcare Provider Details

I. General information

NPI: 1417263336
Provider Name (Legal Business Name): LEAH D PREDUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 11/27/2023
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 EAST CENTRE AVE
PORTAGE MI
49002
US

IV. Provider business mailing address

8001 ANGLING RD
PORTAGE MI
49024-7422
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7050
  • Fax: 269-286-7051
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005839
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: