Provider Demographics
NPI:1467832055
Name:ROGGHE, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ROGGHE
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 1:655 KENMOOR AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-575-1212
Mailing Address - Fax:616-575-1212
Practice Address - Street 1:655 KENMOOR AVE SE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-575-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009168363A00000X
WAPA60569930363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant