Provider Demographics
NPI:1497721047
Name:WITTE, KRISTIN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:WITTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:KAREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 228
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:250 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-6714
Practice Address - Fax:616-685-5260
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION59880Medicare ID - Type Unspecified
MIP32930277Medicare PIN
P75325Medicare UPIN