Basic Information
Provider Information | |||||||||
NPI: | 1366724668 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOSEDA | ||||||||
FirstName: | KARA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VAUGHN | ||||||||
OtherFirstName: | KARA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5900 BYRON CENTER AVE SW | ||||||||
Address2: | MEDICAL ADMINISTRATION | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495199606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162523243 | ||||||||
FaxNumber: | 6162520260 | ||||||||
Practice Location | |||||||||
Address1: | 8941 N RODGERS CT SE | ||||||||
Address2: |   | ||||||||
City: | CALEDONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 49316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6162525300 | ||||||||
FaxNumber: | 6162525390 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2011 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 5601006178 | MI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 5601006178 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.