Provider Demographics
NPI:1235639626
Name:GREW, KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GREW
Suffix:
Gender:F
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 1:4604 AUTUMN RIDGE CIR N
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-6814
Mailing Address - Country:US
Mailing Address - Phone:989-415-2705
Mailing Address - Fax:
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6831
Practice Address - Country:US
Practice Address - Phone:989-894-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant