Provider Demographics
NPI:1356650006
Name:MANCINI, ALICIA MAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MAY
Last Name:MANCINI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ALICIA
Other - Middle Name:MAY
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC-845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-267-7100
Mailing Address - Fax:616-267-7102
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 205
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-7100
Practice Address - Fax:616-267-7102
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002477363AS0400X
MI5601007930363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical