Provider Demographics
NPI:1801986914
Name:ANDERSON, MARCELYN (PA-C)
Entity type:Individual
Prefix:
First Name:MARCELYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:616-486-6557
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:SUITE A721
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2326-023363AM0700X
MI5601006703363AM0700X
IL085002748363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801986914Medicaid
IL118606OtherHEALTH ALLIANCE MEDICAL
WI43025800Medicaid
WI60828OtherDEAN HEALTH INSURANCE
WI43025800Medicaid
WI106274150Medicare PIN