Healthcare Provider Details

I. General information

NPI: 1275050817
Provider Name (Legal Business Name): GINA WOLF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GINA STIVER PA-C

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S US HIGHWAY 131
THREE RIVERS MI
49093-8831
US

IV. Provider business mailing address

601 JOHN STREET BOX 39
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008332
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: