Provider Demographics
NPI:1780686550
Name:PETTIGREW, SUSANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:PETTIGREW
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 1:985 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9563
Mailing Address - Country:US
Mailing Address - Phone:616-252-4655
Mailing Address - Fax:616-252-0103
Practice Address - Street 1:145 MICHIGAN ST NE STE 4400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2564
Practice Address - Country:US
Practice Address - Phone:616-486-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001592363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical