Provider Demographics
NPI:1922108083
Name:GOORMAN, AMY BETH (NP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:GOORMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:BETH
Other - Last Name:RUITER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:616-459-0044
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704192008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382285194OtherTAX ID
MI382285194OtherTAX ID
MIS46152Medicare UPIN