Provider Demographics
NPI:1174185771
Name:MCCALLISTER, MICHAEL DAVID
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MCCALLISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8223 GLENWYND DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9680
Mailing Address - Country:US
Mailing Address - Phone:269-760-3434
Mailing Address - Fax:
Practice Address - Street 1:3770 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0700
Practice Address - Country:US
Practice Address - Phone:269-329-2887
Practice Address - Fax:269-329-2805
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311437363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner