Provider Demographics
NPI:1891990420
Name:TEFT, KELLY S (PA-C)
Entity Type:Individual
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First Name:KELLY
Middle Name:S
Last Name:TEFT
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:SUITE 8861
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-0800
Practice Address - Fax:616-391-0801
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2021-03-03
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Provider Licenses
StateLicense IDTaxonomies
MI5601004983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460653Medicare PIN