Basic Information
| Provider Information | |||||||||
| NPI: | 1598223612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROOSSIEN | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666111512 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15151 STANTON ST | ||||||||
| Address2: | |||||||||
| City: | WEST OLIVE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494608543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162961020 | ||||||||
| FaxNumber: | 6162961030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2019 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 5601004733 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5601004733 | 01 | MI | LICENSE | OTHER |