Provider Demographics
NPI:1003892696
Name:WEGNER, JOHN M (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:WEGNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 ABBEY LN
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9137
Mailing Address - Country:US
Mailing Address - Phone:989-317-0335
Mailing Address - Fax:
Practice Address - Street 1:300 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1014
Practice Address - Country:US
Practice Address - Phone:989-466-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0153701280OtherBCBSM
MIM17400021Medicare PIN
MIS77525Medicare UPIN
MIMI1609020Medicare PIN
MI0153701280OtherBCBSM