Basic Information
| Provider Information | |||||||||
| NPI: | 1497005474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLODGETT | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 330 E BELTLINE AVE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526235 | ||||||||
| FaxNumber: | 6163288176 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 E BELTLINE AVE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526235 | ||||||||
| FaxNumber: | 6163288176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601006479 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.