Provider Demographics
NPI:1972243590
Name:PESTUN MOORE, KATHERINE LEIGH (DO)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LEIGH
Last Name:PESTUN MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LEIGH
Other - Last Name:PESTUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 E MICHIGAN AVE STE 245
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1897
Mailing Address - Country:US
Mailing Address - Phone:517-364-5710
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015428APP22207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine