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NPI Code Detail

MEDICARE: KAYLA R LICARI P.A.-C

MEDICARE: KAYLA R LICARI P.A.-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician Assistant5601005659MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15601005659OTHERMISTATE LICENSE

General Provider Information

NPI Number : 1770811903
Entity Type Code : Individual
Provider Name (Legal Business Name) : KAYLA R LICARI P.A.-C
Provider Business Mailing Address
First Line : 3700 52ND ST SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49512-9637
Country : US
Telephone Number : 616-656-3700
Fax Number : 616-656-3701
Provider Business Practice Location Address
First Line : 3700 52ND ST SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49512-9637
Country : US
Telephone Number : 616-656-3700
Fax Number : 616-656-3701
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2009
Last Update Date : 11/30/2009

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Directions to “ KAYLA R LICARI P.A.-C” Practice Location

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