Provider Demographics
NPI:1033493309
Name:SURROCK, LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SURROCK
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 1:154 S MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1692
Mailing Address - Country:US
Mailing Address - Phone:989-502-1122
Mailing Address - Fax:989-502-1212
Practice Address - Street 1:154 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1692
Practice Address - Country:US
Practice Address - Phone:989-502-1122
Practice Address - Fax:989-502-1212
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M32030OtherMEDICARE PTAN
MI1033493309Medicaid
1033493309OtherNPI
M23560368OtherMEDICARE
1225547383OtherTYPE 2 NPI
1225547383OtherNPI TYPE 2 - FRANKENMUTH MEDICAL ASSOCIATES