Provider Demographics
NPI:1033138581
Name:WAZNY, MARIELLEN (PAC)
Entity Type:Individual
Prefix:
First Name:MARIELLEN
Middle Name:
Last Name:WAZNY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4555
Mailing Address - Country:US
Mailing Address - Phone:989-633-1350
Mailing Address - Fax:989-633-1353
Practice Address - Street 1:3009 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4555
Practice Address - Country:US
Practice Address - Phone:989-633-1350
Practice Address - Fax:989-633-1353
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1008807OtherNCCPA# WAZNY