Provider Demographics
NPI:1932202058
Name:KEUR, ELLYN (PA)
Entity Type:Individual
Prefix:
First Name:ELLYN
Middle Name:
Last Name:KEUR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845 ATTN JULIE L
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6772
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:2332 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1955
Practice Address - Country:US
Practice Address - Phone:616-391-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598712390OtherGROUP NPI
MI0M94800033Medicare ID - Type UnspecifiedMEDICARE
MIP00343186Medicare ID - Type UnspecifiedRAILROAD