Provider Demographics
NPI:1558385849
Name:VALLANCE, TAWNA W (PA C)
Entity type:Individual
Prefix:
First Name:TAWNA
Middle Name:W
Last Name:VALLANCE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 BAKER ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-733-6607
Mailing Address - Fax:231-737-0534
Practice Address - Street 1:2700 BAKER ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-733-6607
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002959363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M15940Medicare ID - Type Unspecified
MI231858Medicare Oscar/Certification
MIS61644Medicare UPIN