Provider Demographics
NPI:1730153495
Name:GENZINK, RYAN PENNING (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:PENNING
Last Name:GENZINK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:CHRISTOPHER
Other - Last Name:GENZINK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
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 1:7751 BYRON CENTER AVE SW STE C
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8001
Practice Address - Country:US
Practice Address - Phone:616-267-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5601003488363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N48650005Medicare PIN
P51636Medicare UPIN