Provider Demographics
NPI:1922283993
Name:KILLEEN, ANNA (PA-C)
Entity Type:Individual
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First Name:ANNA
Middle Name:
Last Name:KILLEEN
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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:616-486-6557
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:588 E LAKEWOOD BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2023
Practice Address - Country:US
Practice Address - Phone:616-494-5810
Practice Address - Fax:616-494-5901
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2020-12-04
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Provider Licenses
StateLicense IDTaxonomies
MI5601004321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922283993Medicaid
MI1922283993Medicaid