Provider Demographics
NPI:1386796662
Name:MACDONALD, KIMBERLY ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-6902
Practice Address - Fax:616-685-8995
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056757363A00000X
OH50-002531363A00000X
WI2390-23363A00000X
MI5601007425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3233523Medicare PIN