Basic Information
| Provider Information | |||||||||
| NPI: | 1275984700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINE HOLLOW PARTNER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 PINE HOLLOW DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488239700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
| FaxNumber: | 5173392716 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 PINE HOLLOW DR | ||||||||
| Address2: | STE 400 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488239700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
| FaxNumber: | 5173392716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | ZINK | ||||||||
| AuthorizedOfficialFirstName: | IRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5173391676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.