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General NPI Number Information
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NPI Number | 1114234325
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Entity Type | Individual
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Provider Name | TIMOTHY A KRAGT MS, PA-C
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Gender | Male
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Dates
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Enumeration Date | 09/09/2010
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Last Update Date | 10/14/2015
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Provider Practice Location Address
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Address Line | 100 MICHIGAN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2560
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Country | US
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Telephone | 616-391-1680
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Fax |
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Provider Business Mailing Address
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Address Line | 3264N EVERGREEN NEDR
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9746
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Country | US
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Telephone | 616-363-7339
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Fax | 616-361-5828
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601005832
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License Number State | MI
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