Provider Demographics
NPI:1215369251
Name:WAISANEN, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WAISANEN
Suffix:
Gender:M
Credentials:PA-C
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP B
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-8857
Practice Address - Fax:734-615-2656
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
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Provider Licenses
StateLicense IDTaxonomies
MI5601006639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant