Provider Demographics
NPI:1902990583
Name:TEW, KIMBERLY (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 CONRAN DR
Practice Address - Street 2:SUITE B
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1366
Practice Address - Country:US
Practice Address - Phone:616-267-7860
Practice Address - Fax:616-267-7861
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M94800034Medicare ID - Type UnspecifiedMEDICARE
MIM74460581Medicare PIN