Provider Demographics
NPI:1477815454
Name:OVNOVIC-FAROOK, NINA (PA-C)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:OVNOVIC-FAROOK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:OVNOVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 246
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3691
Practice Address - Country:US
Practice Address - Phone:616-391-3323
Practice Address - Fax:616-391-3330
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant