Provider Demographics
NPI:1003896382
Name:WIESE, COLLIER S (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLIER
Middle Name:S
Last Name:WIESE
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 1:1541 GULL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1639
Mailing Address - Country:US
Mailing Address - Phone:269-343-1264
Mailing Address - Fax:269-343-9555
Practice Address - Street 1:1541 GULL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1639
Practice Address - Country:US
Practice Address - Phone:269-343-1264
Practice Address - Fax:269-343-9555
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP18520003Medicare ID - Type Unspecified
MION73570Medicare UPIN