Provider Demographics
NPI:1710086574
Name:VAITKEVICIUS, HENRIKAS ERWIN (PA)
Entity Type:Individual
Prefix:
First Name:HENRIKAS
Middle Name:ERWIN
Last Name:VAITKEVICIUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3536
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3536
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-975-1845
Practice Address - Street 1:100 MICHIGAN NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-391-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P13056Medicare UPIN
N30180004Medicare ID - Type Unspecified