Provider Demographics
NPI:1750566709
Name:MORETTA, GUSTAVO A (NP)
Entity type:Individual
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First Name:GUSTAVO
Middle Name:A
Last Name:MORETTA
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Gender:M
Credentials:NP
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:1900 WEALTHY ST SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2969
Practice Address - Country:US
Practice Address - Phone:616-774-0276
Practice Address - Fax:616-774-5401
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2021-06-15
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Provider Licenses
StateLicense IDTaxonomies
MI4704184760363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750566709Medicaid
MIM53750062Medicare PIN