Basic Information
| Provider Information | |||||||||
| NPI: | 1306828298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WUENSCH | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 S STEPHENSON AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765800 | ||||||||
| FaxNumber: | 9062280200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 1204023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601003229 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00297697 | 01 | WI | RR MEDICARE | OTHER | 0852210320 | 01 | MI | BCBS MI | OTHER | 42868400 | 05 | WI | MEDICAID |