Provider Demographics
NPI:1669014130
Name:VANDERBROEK, COURTNEY T (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:T
Last Name:VANDERBROEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:T
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3902 MAYFIELD AVE NE APT 2B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6601
Mailing Address - Country:US
Mailing Address - Phone:810-626-8829
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5377
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant