Provider Demographics
NPI:1689824948
Name:HOLMSTROM-BAKER, KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:HOLMSTROM-BAKER
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 1:3902 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-2545
Mailing Address - Country:US
Mailing Address - Phone:313-562-1985
Mailing Address - Fax:
Practice Address - Street 1:3902 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-2545
Practice Address - Country:US
Practice Address - Phone:313-562-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant