Provider Demographics
NPI:1902387962
Name:EVENHOUSE, AMELIA LOUISE (PA)
Entity Type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:LOUISE
Last Name:EVENHOUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:LOUISE
Other - Last Name:VERDUZCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5623 GULL RD STE 500
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1098
Practice Address - Country:US
Practice Address - Phone:269-775-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008773363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902387962Medicaid