Provider Demographics
NPI:1356530919
Name:SOUKUP, ANN E (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:E
Last Name:SOUKUP
Suffix:
Gender:F
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 1:900 PEELER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2380
Mailing Address - Country:US
Mailing Address - Phone:269-345-8618
Mailing Address - Fax:269-345-1508
Practice Address - Street 1:900 PEELER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2380
Practice Address - Country:US
Practice Address - Phone:269-345-8618
Practice Address - Fax:269-345-1508
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN93340005OtherMEDICARE PTAN
MI5601001432OtherMI LICENSE