Provider Demographics
NPI:1255457677
Name:LEFFLER, GRETCHEN (PAC)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:LEFFLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:MICHALOWSKI (LEFFLER)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5629 STADIUM DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1952
Mailing Address - Country:US
Mailing Address - Phone:269-372-5701
Mailing Address - Fax:269-372-5702
Practice Address - Street 1:5629 STADIUM DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-5701
Practice Address - Fax:269-372-5702
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004107363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C910950OtherBCBSM
MI1255457677Medicaid
MI700C910950OtherBCBSM