Basic Information
| Provider Information | |||||||||
| NPI: | 1992960033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISNIEWSKI | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10850 E TRAVERSE HWY | ||||||||
| Address2: | SUITE 4400 | ||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496841364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313466800 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 E PARKDALE AVE | ||||||||
| Address2: | |||||||||
| City: | MANISTEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496609709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313981000 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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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 | 5601005972 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.