Provider Demographics
NPI:1336669993
Name:GJETAJ, KENDALL ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:ROSE
Last Name:GJETAJ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:ROSE
Other - Last Name:BELSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2674 W JEFFERSON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2800
Mailing Address - Country:US
Mailing Address - Phone:313-483-3262
Mailing Address - Fax:734-642-9202
Practice Address - Street 1:115 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5524
Practice Address - Country:US
Practice Address - Phone:248-828-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant