MEDICARE: MARYLYNN JOANNA GAASTRA PA

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
1	207R00000X	Internal Medicine Physician	5601006007	MI

General Provider Information

NPI Number	:	1841582327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYLYNN JOANNA GAASTRA PA

Provider Business Mailing Address
First Line	:	2749 COIT AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-3505
Country	:	US
Telephone Number	:	616-745-0956
Fax Number	:

Provider Business Practice Location Address
First Line	:	4118 KALAMAZOO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3605
Country	:	US
Telephone Number	:	231-780-6080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	06/06/2016

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