Provider Demographics
NPI:1053838169
Name:STOUT, DANIEL SIMON (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SIMON
Last Name:STOUT
Suffix:
Gender:M
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 1:12576 POINT DR
Mailing Address - Street 2:
Mailing Address - City:GOWEN
Mailing Address - State:MI
Mailing Address - Zip Code:49326-9718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:669 STOCKING AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5176
Practice Address - Country:US
Practice Address - Phone:616-235-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008348363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical