Healthcare Provider Details

I. General information

NPI: 1013506625
Provider Name (Legal Business Name): KATELYN GOFF PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 PARK EAST CT SE
GRAND RAPIDS MI
49546-8810
US

IV. Provider business mailing address

20095 GILBERT RD
BIG RAPIDS MI
49307-2365
US

V. Phone/Fax

Practice location:
  • Phone: 231-592-1360
  • Fax: 231-592-1361
Mailing address:
  • Phone: 231-592-1360
  • Fax: 231-592-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: