Provider Demographics
NPI:1104889468
Name:PIERSMA, CRAIG A (PT)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:PIERSMA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MICHIGAN AVE 220
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-355-4284
Mailing Address - Fax:
Practice Address - Street 1:601 MICHIGAN AVE 220
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-355-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIQ28423Medicare UPIN
WI000180275Medicare ID - Type Unspecified
WI40441300Medicaid