Healthcare Provider Details

I. General information

NPI: 1760031157
Provider Name (Legal Business Name): MICHAEL NESTORAK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

125 S KALAMAZOO MALL STE 204
KALAMAZOO MI
49007-4869
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-7654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5601009565
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: