Provider Demographics
NPI:1164472619
Name:DECKER, KIMBERLY K (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:DECKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-363-7339
Practice Address - Street 1:3355 EAGLE PARK DR NE
Practice Address - Street 2:SUITE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7004
Practice Address - Country:US
Practice Address - Phone:616-942-7400
Practice Address - Fax:616-942-7405
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004650OtherMICHIGAN LICENSE
N93440003Medicare PIN