MEDICARE: MS. ELIZABETH JOANNE ANDERSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601004734	MI

General Provider Information

NPI Number	:	1629158399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH JOANNE ANDERSON PA-C

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 68TH ST SE
Second Line	:	SUITE 100
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7896
Country	:	US
Telephone Number	:	616-267-7881
Fax Number	:	616-267-7641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	02/24/2021

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