Provider Demographics
NPI:1780737130
Name:KILLINGBECK, DAVID A (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:KILLINGBECK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:YALE
Mailing Address - State:MI
Mailing Address - Zip Code:48097-2835
Mailing Address - Country:US
Mailing Address - Phone:810-387-9715
Mailing Address - Fax:
Practice Address - Street 1:703 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1440
Practice Address - Country:US
Practice Address - Phone:989-386-5120
Practice Address - Fax:989-802-8880
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S74704Medicare UPIN