Healthcare Provider Details

I. General information

NPI: 1679397640
Provider Name (Legal Business Name): JUSTIN ROBERT KAPKE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14695 PARK AVE STE A
CHARLEVOIX MI
49720-1920
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 321-487-2270
  • Fax:
Mailing address:
  • Phone: 231-935-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012888
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: