Individual
EVAN GERONDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1740 E PARIS AVE SE, GRAND RAPIDS, MI 49546-6204
(616) 949-5600
(616) 949-6571
Mailing address
1740 E PARIS AVE SE, GRAND RAPIDS, MI 49546-6204
(616) 949-5600
(616) 949-6571
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
5601010425
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5601010425
STATE LICENSE
MI
Enumeration date
01/29/2021
Last updated
04/14/2022
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