Provider Demographics
NPI:1346260007
Name:KOOISTRA, MELISSA A (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:KOOISTRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:VANTOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3940 PENINSULAR DRIVE SE
Mailing Address - Street 2:STE 230
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6187
Mailing Address - Country:US
Mailing Address - Phone:616-366-4234
Mailing Address - Fax:855-548-4481
Practice Address - Street 1:3940 PENINSULAR DRIVE SE
Practice Address - Street 2:STE 230
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6187
Practice Address - Country:US
Practice Address - Phone:616-366-4234
Practice Address - Fax:855-548-4481
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
110D111790OtherBCBSM GP
MI1558407189OtherGROUP NPI
110D111790OtherBCBSM GP
MI1558407189OtherGROUP NPI
Q18618Medicare UPIN