Provider Demographics
NPI:1679767222
Name:SUPIANOSKI, KATE MERYL (PA)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:MERYL
Last Name:SUPIANOSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:MERYL
Other - Last Name:SHARPHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD
Practice Address - Street 2:STE 420
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-884-6100
Practice Address - Fax:517-884-6233
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005114363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679767222Medicaid
MIC36088123Medicare PIN
MI0C36088123Medicare PIN