Provider Demographics
NPI:1134138480
Name:FOCHT, KATIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:FOCHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ULLERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1129 COBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-8726
Mailing Address - Country:US
Mailing Address - Phone:616-893-8995
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1896
Practice Address - Country:US
Practice Address - Phone:517-253-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004558OtherSTATE LICENSE NUMBER
MION88600Medicare ID - Type Unspecified