Provider Demographics
NPI:1497005474
Name:PETERSON, GINA RENEE (PA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:RENEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RENEE
Other - Last Name:BLODGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1267
Mailing Address - Country:US
Mailing Address - Phone:616-752-6235
Mailing Address - Fax:616-328-8176
Practice Address - Street 1:330 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1267
Practice Address - Country:US
Practice Address - Phone:616-752-6235
Practice Address - Fax:616-328-8176
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID17643105Medicare PIN
MI1497005474Medicaid