Healthcare Provider Details

I. General information

NPI: 1568131001
Provider Name (Legal Business Name): WYNNETH HUANG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 SHAFFER ST STE 124
KALAMAZOO MI
49048-1629
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 269-226-5456
  • Fax: 269-226-4940
Mailing address:
  • Phone: 269-552-2823
  • Fax: 269-552-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: