Provider Demographics
NPI:1760760037
Name:RODRIGUEZ, CRISTIAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CRISTIAN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
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 1:2155 BUCHANAN ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-247-3638
Mailing Address - Fax:
Practice Address - Street 1:2155 BUCHANAN ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-247-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006045363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant