Healthcare Provider Details

I. General information

NPI: 1114683588
Provider Name (Legal Business Name): KIRSTEN CRAWFORD PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 EYDE PKWY
EAST LANSING MI
48823-6817
US

IV. Provider business mailing address

3814 CAMELOT DR SE APT 2B
GRAND RAPIDS MI
49546-6046
US

V. Phone/Fax

Practice location:
  • Phone: 517-333-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: