Basic Information
| Provider Information | |||||||||
| NPI: | 1871574046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFSEN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | VICKY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1847 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317274444 | ||||||||
| FaxNumber: | 2317284789 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601004565 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | N34010014 | 01 | MEDICARE MERCY | OTHER | ON34010 | 01 | MEDICARE GROU NO. MERCY | OTHER |