Provider Demographics
NPI:1891990701
Name:SUMMEY, MEGHAN MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:MARIE
Last Name:SUMMEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MEGHAN
Other - Middle Name:MARIE
Other - Last Name:BULGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:985 GEZON PKWY SW
Mailing Address - Street 2:ATTN: TERESA MCNALLY
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 1:1925 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4810
Practice Address - Country:US
Practice Address - Phone:616-252-4100
Practice Address - Fax:616-252-4953
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1891990701Medicaid
MI5601005000OtherSTATE LICENSE NUMBER
MI1891990701Medicaid