Provider Demographics
NPI:1780676551
Name:DORSEY, THEODORE A (PA-C)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:DORSEY
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 1:100 MICHIGAN STREET NE MC 845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2009 HOLTON RD
Practice Address - Street 2:
Practice Address - City:N MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1578
Practice Address - Country:US
Practice Address - Phone:231-291-8399
Practice Address - Fax:231-291-8397
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN33870011OtherMEDICARE PTAN
0N79570Medicare ID - Type Unspecified
S56098Medicare UPIN