Provider Demographics
NPI:1518141522
Name:TEITSMA, ERIN N (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:N
Last Name:TEITSMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:N
Other - Last Name:GOHLKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2537 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:616-988-8220
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN30180053Medicare PIN