Provider Demographics
NPI:1851594501
Name:PEBBLES, THERESA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JEAN
Last Name:PEBBLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JEAN
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1310 WISCONSIN STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:616-844-4528
Mailing Address - Fax:616-847-5608
Practice Address - Street 1:1310 WISCONSIN STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-847-1860
Practice Address - Fax:616-844-4670
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
N48650051Medicare PIN