Provider Demographics
NPI:1104909753
Name:SPIESS, MARIE L (PA-C)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:SPIESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:818 W KING ST
Mailing Address - Street 2:STE 201
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2116
Mailing Address - Country:US
Mailing Address - Phone:989-723-3168
Mailing Address - Fax:989-725-2962
Practice Address - Street 1:818 W KING ST
Practice Address - Street 2:STE 201
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2116
Practice Address - Country:US
Practice Address - Phone:989-723-3168
Practice Address - Fax:989-725-2962
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104909753Medicaid
MIN57610019Medicare PIN
MI1104909753Medicaid