Provider Demographics
NPI:1205196458
Name:MATHEW, EMILY SUZANNE (NP,RN, APN)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:SUZANNE
Last Name:MATHEW
Suffix:
Gender:F
Credentials:NP,RN, APN
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:SUZANNE
Other - Last Name:HOLTVLUWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:5950 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9514
Practice Address - Country:US
Practice Address - Phone:616-252-8100
Practice Address - Fax:616-252-8181
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX745774363L00000X
TXAP122357363L00000X
MI4704240951363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01879999OtherRAILROAD
TX305234201Medicaid
TX885N91OtherBCBS
TX305234202Medicaid
MI4704240951OtherSTATE LICENSE
TX885N91OtherBCBS
TXB160294Medicare PIN