Provider Demographics
NPI:1740488683
Name:MUKARURINDA, LEONCIE (PA)
Entity type:Individual
Prefix:
First Name:LEONCIE
Middle Name:
Last Name:MUKARURINDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8719
Mailing Address - Fax:616-840-9637
Practice Address - Street 1:235 WEALTHY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5229
Practice Address - Country:US
Practice Address - Phone:616-840-8719
Practice Address - Fax:616-870-9637
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant