Provider Demographics
NPI:1780995902
Name:BUSSONE, KATHERINE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:BUSSONE
Suffix:
Gender:F
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:3185 MACATAWA DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3184
Practice Address - Country:US
Practice Address - Phone:616-391-4500
Practice Address - Fax:616-486-0130
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN38550112Medicare PIN
MID16321066Medicare PIN