Provider Demographics
NPI:1306395322
Name:LUNGARO, THERESE (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:LUNGARO
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 1:3232 N WELLNESS DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8027
Mailing Address - Country:US
Mailing Address - Phone:616-494-4250
Mailing Address - Fax:616-494-4261
Practice Address - Street 1:15100 WHITTAKER WAY
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8696
Practice Address - Country:US
Practice Address - Phone:616-935-6210
Practice Address - Fax:616-935-6215
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant