Provider Demographics
NPI:1235130576
Name:WIESE, CAROLYN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 MITCHELL PARK DR STE D
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-487-7200
Mailing Address - Fax:231-487-7188
Practice Address - Street 1:2390 MITCHELL PARK DR STE D
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-7200
Practice Address - Fax:231-487-7188
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001143363AM0700X
MI5601003704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235130576Medicaid
ME0008897OtherMEDICARE PTAN
MEP00671911OtherRAILROAD MEDICARE