Provider Demographics
NPI:1841582327
Name:GAASTRA, MARYLYNN JOANNA (PA)
Entity Type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:JOANNA
Last Name:GAASTRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2749 COIT AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3505
Mailing Address - Country:US
Mailing Address - Phone:616-745-0956
Mailing Address - Fax:
Practice Address - Street 1:4118 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3605
Practice Address - Country:US
Practice Address - Phone:231-780-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine