Provider Demographics
NPI:1093023228
Name:NEVENZEL, LESLEY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:ANN
Last Name:NEVENZEL
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 1:100 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 1:2009 HOLTON RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1578
Practice Address - Country:US
Practice Address - Phone:616-935-3479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093023228OtherBLUE CROSS BLUE SHIELD TRAD, TRUST, AND MEDICARE BLUE CROSS
MIP00925484OtherRAILROAD MEDICARE
MI1417961137OtherBCBSM - BRONSON
MI1851569958OtherBLUE CROSS BLUE SHIELD TRAD, TRUST, AND MEDICARE BLUE CROSS
MI1093023228Medicaid
MI1053901340OtherBLUE CROSS BLUE SHIELD TRAD, TRUST, AND MEDICARE BLUE CROSS
MI1093023228OtherRAILROAD MEDICARE
MIP00925484OtherRAILROAD MEDICARE
MI1851569958Medicare PIN
MI1851569958OtherBLUE CROSS BLUE SHIELD TRAD, TRUST, AND MEDICARE BLUE CROSS
MI1053901340OtherBLUE CROSS BLUE SHIELD TRAD, TRUST, AND MEDICARE BLUE CROSS
MIP00925484Medicare PIN
MIDN1294Medicare PIN