Provider Demographics
NPI:1942862107
Name:VANDEWALKER, ROSE LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:LAUREN
Last Name:VANDEWALKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:LAUREN
Other - Last Name:CLOUSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant