Provider Demographics
NPI:1730625880
Name:KENT, SIOBHAN MAIREAD (PA-C)
Entity type:Individual
Prefix:
First Name:SIOBHAN
Middle Name:MAIREAD
Last Name:KENT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 2045
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-3098
Practice Address - Fax:616-685-3095
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant