Provider Demographics
NPI:1194812180
Name:GANZOW-FORTIER, REBECCA M (PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:GANZOW-FORTIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-775-6521
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:1615 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7984
Practice Address - Country:US
Practice Address - Phone:231-745-4624
Practice Address - Fax:231-745-4928
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3068-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI741501952Medicare PIN
WI543401689Medicare PIN
WI741501952Medicare PIN