Provider Demographics
NPI:1669424719
Name:BEEZLEY, ANGELA L (PAC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:BEEZLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:616-389-1766
Practice Address - Street 1:6425 S. HARVEY ST.
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9739
Practice Address - Country:US
Practice Address - Phone:231-737-3469
Practice Address - Fax:231-737-4548
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004502363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7481016Medicare PIN