Provider Demographics
NPI:1750399986
Name:VANSUMEREN, KENNETH (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VANSUMEREN
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 1:301 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2761
Mailing Address - Country:US
Mailing Address - Phone:989-832-0900
Mailing Address - Fax:989-633-0349
Practice Address - Street 1:301 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2761
Practice Address - Country:US
Practice Address - Phone:989-832-0900
Practice Address - Fax:989-633-0349
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N59990Medicare ID - Type Unspecified