=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932202058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLYN KEUR PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 11/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2332 ALPINE AVE NW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49544-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-391-6220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MICHIGAN ST NE MC 845 ATTN JULIE L
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-2560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-486-6772
-----------------------------------------------------
Fax | 616-486-6702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601001633
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------