Provider Demographics
NPI:1992960033
Name:WISNIEWSKI, NICOLE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6800
Mailing Address - Fax:989-340-1214
Practice Address - Street 1:1465 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9709
Practice Address - Country:US
Practice Address - Phone:231-398-1000
Practice Address - Fax:989-340-1214
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2016-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005972363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF06016085Medicare PIN