Healthcare Provider Details

I. General information

NPI: 1053665893
Provider Name (Legal Business Name): KATHLEEN R WOODS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN R POTTS PA-C

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

893 E SUPERIOR ST
WAYLAND MI
49348-9178
US

IV. Provider business mailing address

2122 HEALTH DR SW SUITE 230
WYOMING MI
49519-9698
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: