Provider Demographics
NPI:1669280384
Name:GUALTIERI, MIKALA RAE (PA)
Entity type:Individual
Prefix:
First Name:MIKALA
Middle Name:RAE
Last Name:GUALTIERI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7050
Mailing Address - Country:US
Mailing Address - Phone:616-510-6407
Mailing Address - Fax:
Practice Address - Street 1:3570 HENRY ST STE 120
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-4576
Practice Address - Country:US
Practice Address - Phone:231-672-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012938APP24207Q00000X
MI5601012938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine