Provider Demographics
NPI:1033282520
Name:KORNELI-GRADOWSKI, KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KORNELI-GRADOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:KORNELI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:461 W HURON ST
Mailing Address - Street 2:NOMC FAMILY PRACTICE CENTER
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1601
Mailing Address - Country:US
Mailing Address - Phone:248-857-7160
Mailing Address - Fax:248-857-7141
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:NOMC FAMILY PRACTICE CENTER
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7160
Practice Address - Fax:248-857-7141
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant