Basic Information
| Provider Information | |||||||||
| NPI: | 1457416166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIERSEMA | ||||||||
| FirstName: | CHANNING | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 PLOVER RD | ||||||||
| Address2: | |||||||||
| City: | PLOVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544673916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152953800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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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 | 207Q00000X | 38945 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32381800 | 05 | WI | MEDICAID |