Provider Demographics
NPI:1801862842
Name:STACHOWIAK, KATRINA LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LOUISE
Last Name:STACHOWIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:LOUISE
Other - Last Name:BERGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7470 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3458
Mailing Address - Country:US
Mailing Address - Phone:810-387-9355
Mailing Address - Fax:810-387-9400
Practice Address - Street 1:7470 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3458
Practice Address - Country:US
Practice Address - Phone:810-387-9355
Practice Address - Fax:810-387-9400
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801862842Medicaid
P53644Medicare UPIN