Provider Demographics
NPI:1790893014
Name:FONGERS, MAURICE EUGENE III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:EUGENE
Last Name:FONGERS
Suffix:III
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 ST NE
Mailing Address - Street 2:MC845
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 1:707 S GREENVILLE WEST DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3514
Practice Address - Country:US
Practice Address - Phone:616-754-3001
Practice Address - Fax:616-754-3828
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M74460415Medicare PIN
MI0N38550094Medicare PIN