Provider Demographics
NPI:1245204965
Name:MONTERUSSO, KAREN ARDEL (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ARDEL
Last Name:MONTERUSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:ARDEL
Other - Last Name:SCHUMAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-242-2512
Practice Address - Street 1:2060 E PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1154
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110D111790OtherBCBSM
MI110D111790OtherBCBSM
N48650042Medicare ID - Type Unspecified