Provider Demographics
NPI:1508916800
Name:KUT, MICHELLE KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KRISTINE
Last Name:KUT
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 1:25599 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4975
Mailing Address - Country:US
Mailing Address - Phone:586-772-6000
Mailing Address - Fax:586-772-7700
Practice Address - Street 1:25599 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4975
Practice Address - Country:US
Practice Address - Phone:586-772-6000
Practice Address - Fax:586-772-7700
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003976363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003976OtherPHYSICIAN ASST LICENSE
MICD7959OtherRAILROAD MEDICARE
MICD7957OtherRAILROAD MEDICARE
MICD7957OtherRAILROAD MEDICARE