Healthcare Provider Details

I. General information

NPI: 1013472695
Provider Name (Legal Business Name): MICAH NAHUM FOSTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 DEL MAR DR SW STE C
WYOMING MI
49418-8870
US

IV. Provider business mailing address

4050 DEL MAR DR SW STE C
WYOMING MI
49418-8870
US

V. Phone/Fax

Practice location:
  • Phone: 616-317-4807
  • Fax:
Mailing address:
  • Phone: 616-317-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008858
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: