Healthcare Provider Details

I. General information

NPI: 1275304099
Provider Name (Legal Business Name): KRISHNA B BISTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date: 04/02/2024
Reactivation Date: 09/21/2026

III. Provider practice location address

3107 BLUE SPRUCE CT SE
KENTWOOD MI
49512-2872
US

IV. Provider business mailing address

3167 BLAIRVIEW PKWY SE APT 201
KENTWOOD MI
49512-1798
US

V. Phone/Fax

Practice location:
  • Phone: 616-219-5543
  • Fax: 616-469-1246
Mailing address:
  • Phone: 616-219-5543
  • Fax: 616-469-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: