Basic Information
| Provider Information | |||||||||
| NPI: | 1699708875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUTTLE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 COMMERCE AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169400660 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 LAKE DR SE | ||||||||
| Address2: | STE 305 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162851377 | ||||||||
| FaxNumber: | 6162851006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601001502 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.