Basic Information
| Provider Information | |||||||||
| NPI: | 1003892696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEGNER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 ABBEY LN | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488589137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893170335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894663228 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601002998 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0153701280 | 01 | MI | BCBSM | OTHER |