Provider Demographics
NPI:1720119522
Name:GRACE, KATHY A (PAC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:GRACE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE WAY STE A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4271
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:517-374-9042
Practice Address - Street 1:839 S PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1623
Practice Address - Country:US
Practice Address - Phone:517-655-3515
Practice Address - Fax:517-655-3743
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI003250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI085330405OtherBCBS PIN
MI1720119522Medicaid
MIP83088Medicare UPIN
MIM98740006Medicare PIN