Provider Demographics
NPI:1831166511
Name:KONRAD, KARIN (PA)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:KONRAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KARIN
Other - Middle Name:
Other - Last Name:COFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N PATTERSON RD
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-8041
Practice Address - Country:US
Practice Address - Phone:616-885-5000
Practice Address - Fax:616-885-5020
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831166511Medicaid
MI5601006296OtherMICHIGAN LICENSE