Most Relevant Information
Provider Data
| NPI Number: | 1003434507 |
| Provider Name: | ETHAN J LACOURT PA-C |
| Entity Type: | Individual |
| Taxonomy Code: | 363A00000X |
| Specialty: | Physician Assistant |
| License Number: | 5601010844 |
Most Important Dates
| Enumeration Date: | 07/10/2020 |
| Last Updated: | 07/29/2024 |
Provider Practice Location
25 MICHIGAN ST NE STE 6100
GRAND RAPIDS
MI
495032561
Practice Location Phone/Fax
| Phone: | 6162677900 |
| Fax: |
Provider Mailing Location
100 MICHIGAN ST NE # MC845
GRAND RAPIDS
MI
495032560
Provider Mailing Phone/Fax
| Phone: | |
| Fax: |