Provider Demographics
NPI:1851482319
Name:GAST, STEPHANIE SUE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SUE
Last Name:GAST
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Gender:F
Credentials:PAC
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:8333 FELCH ST
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2608
Practice Address - Country:US
Practice Address - Phone:616-772-4644
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-02-26
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Provider Licenses
StateLicense IDTaxonomies
MI5601004033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38550 062OtherMEDICARE