Healthcare Provider Details

I. General information

NPI: 1689956633
Provider Name (Legal Business Name): KATIE LYN RUTKOWSKI P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 BOW POINTE DRIVE SUITE 100
CLARKSTON MI
48346-3199
US

IV. Provider business mailing address

5701 BOW POINTE DRIVE SUITE 100
CLARKSTON MI
48346-3199
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2621
  • Fax: 248-625-2622
Mailing address:
  • Phone: 248-625-2621
  • Fax: 248-625-2622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006183
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: