Provider Demographics
NPI:1336730662
Name:GERONDALE, EVAN (PA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GERONDALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 E PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6204
Mailing Address - Country:US
Mailing Address - Phone:616-949-5600
Mailing Address - Fax:616-949-6571
Practice Address - Street 1:1740 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6204
Practice Address - Country:US
Practice Address - Phone:616-949-5600
Practice Address - Fax:616-949-6571
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010425363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601010425OtherSTATE LICENSE