Provider Demographics
NPI:1689956633
Name:RUTKOWSKI, KATIE LYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LYN
Last Name:RUTKOWSKI
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:5701 BOW POINTE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:5701 BOW POINTE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3199
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2622
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2017-08-01
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Provider Licenses
StateLicense IDTaxonomies
MI5601006183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
M39080071Medicare PIN
MI4989355Medicare PIN