Provider Demographics
NPI:1912364100
Name:LATHAM, MEGAN CHRISTINA (PAC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CHRISTINA
Last Name:LATHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:CHRISTINA
Other - Last Name:HAUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 3578
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3578
Mailing Address - Country:US
Mailing Address - Phone:616-685-6781
Mailing Address - Fax:616-685-3064
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-6781
Practice Address - Fax:616-685-3064
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007649363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical