Provider Demographics
NPI:1346260007
Name:KOOISTRA, MELISSA A (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:VANTOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1682
Mailing Address - Country:US
Mailing Address - Phone:616-774-5221
Mailing Address - Fax:616-774-5391
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:MC 426
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-774-5221
Practice Address - Fax:616-774-5391
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558407189OtherGROUP NPI
110D111790OtherBCBSM GP
110D111790OtherBCBSM GP
MI1558407189OtherGROUP NPI
Q18618Medicare UPIN