MEDICARE: KYLEIGH CHRISTINE EGNATUK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1528711108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLEIGH CHRISTINE EGNATUK PA-C

Provider Business Mailing Address
First Line	:	4024 PARK EAST CT SE STE C
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8810
Country	:	US
Telephone Number	:	616-975-1186
Fax Number	:

Provider Business Practice Location Address
First Line	:	4024 PARK EAST CT SE STE C
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8810
Country	:	US
Telephone Number	:	616-975-1186
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2022
Last Update Date	:	09/13/2023

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