Provider Demographics
NPI:1245577865
Name:KOVATCH, ALEICA L (PA)
Entity Type:Individual
Prefix:
First Name:ALEICA
Middle Name:L
Last Name:KOVATCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2149
Mailing Address - Country:US
Mailing Address - Phone:616-252-5760
Mailing Address - Fax:
Practice Address - Street 1:4055 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2149
Practice Address - Country:US
Practice Address - Phone:616-252-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant