Healthcare Provider Details

I. General information

NPI: 1255457677
Provider Name (Legal Business Name): GRETCHEN LEFFLER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETCHEN MICHALOWSKI (LEFFLER)

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/27/2023
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 STADIUM DRIVE SUITE D
KALAMAZOO MI
49009-1952
US

IV. Provider business mailing address

5629 STADIUM DR SUITE D
KALAMAZOO MI
49009-1952
US

V. Phone/Fax

Practice location:
  • Phone: 269-372-5701
  • Fax: 269-372-5702
Mailing address:
  • Phone: 269-372-5701
  • Fax: 269-372-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004107
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: