Provider Demographics
NPI:1114193356
Name:RUSTENHOLTZ, KIPP EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KIPP
Middle Name:EDWARD
Last Name:RUSTENHOLTZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 TEAKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9734
Mailing Address - Country:US
Mailing Address - Phone:517-339-0188
Mailing Address - Fax:
Practice Address - Street 1:1881 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1840
Practice Address - Country:US
Practice Address - Phone:517-339-2100
Practice Address - Fax:517-339-4620
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant