Provider Demographics
NPI:1467421008
Name:LOCKREM, KRISTIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:J
Last Name:LOCKREM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:J
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:551 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-686-5800
Mailing Address - Fax:269-686-5899
Practice Address - Street 1:406 N STATE ST
Practice Address - Street 2:
Practice Address - City:GOBLES
Practice Address - State:MI
Practice Address - Zip Code:49055-9717
Practice Address - Country:US
Practice Address - Phone:269-628-2196
Practice Address - Fax:269-628-2363
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003243363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKM003243OtherBCBS MI
MI003243OtherSTATE LICENSE
MIKM003243OtherBCBS MI
P55262Medicare UPIN