Provider Demographics
NPI:1275050817
Name:WOLF, GINA (PA-C)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:STIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 JOHN STREET
Mailing Address - Street 2:BOX 39
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 S US HIGHWAY 131
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8831
Practice Address - Country:US
Practice Address - Phone:269-286-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008332OtherMICHIGAN PHYSICIAN ASSISTANT TEMPORARY LICENSE