Provider Demographics
NPI:1578931689
Name:BETKER, ANALISE JACQUELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:ANALISE
Middle Name:JACQUELYN
Last Name:BETKER
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 1:7901 ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0714
Mailing Address - Country:US
Mailing Address - Phone:269-324-8600
Mailing Address - Fax:
Practice Address - Street 1:6210 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-286-7030
Practice Address - Fax:269-286-7031
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007476363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical