Provider Demographics
NPI:1982689733
Name:BOUWKAMP, DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOUWKAMP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:2111 12 MILE RD NW
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-9754
Practice Address - Country:US
Practice Address - Phone:616-391-8470
Practice Address - Fax:616-391-8495
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM97380P03Medicare ID - Type Unspecified
MIS65507Medicare UPIN