Healthcare Provider Details

I. General information

NPI: 1114234325
Provider Name (Legal Business Name): TIMOTHY A KRAGT MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

3264N EVERGREEN NEDR
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1680
  • Fax:
Mailing address:
  • Phone: 616-363-7339
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005832
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: