Healthcare Provider Details

I. General information

NPI: 1669556783
Provider Name (Legal Business Name): KRISTA K. MACDONALD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTA KAY ROSSETO PA-C

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE # 220
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

685 PINE MEADOW LN NE
ADA MI
49301-9773
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5170
  • Fax:
Mailing address:
  • Phone: 630-484-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007679
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003409
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003409
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-003409
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: