Provider Demographics
NPI:1669556783
Name:MACDONALD, KRISTA K (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:K
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:KAY
Other - Last Name:ROSSETO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:685 PINE MEADOW LN NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9773
Mailing Address - Country:US
Mailing Address - Phone:630-484-3910
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE # 220
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007679363A00000X
085003409363AM0700X
IL085003409363AM0700X
IL085-003409363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00392993OtherRAILROAD MEDICARE
KYQ77649Medicare UPIN
KY0658612Medicare PIN
IL434330002Medicare PIN