Provider Demographics
NPI:1043755242
Name:DEBRUIN, RACHEL LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LAUREN
Last Name:DEBRUIN
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 1:1700 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5502
Mailing Address - Country:US
Mailing Address - Phone:231-557-3443
Mailing Address - Fax:
Practice Address - Street 1:1700 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5502
Practice Address - Country:US
Practice Address - Phone:231-557-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant