Provider Demographics
NPI:1306828298
Name:WUENSCH, GEORGE P (PAC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:P
Last Name:WUENSCH
Suffix:
Gender:M
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1711 S STEPHENSON AVE STE 210
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3649
Practice Address - Country:US
Practice Address - Phone:906-776-5800
Practice Address - Fax:906-228-0200
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1204023363A00000X
MI5601003229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00297697OtherRR MEDICARE
MI0852210320OtherBCBS MI
WI42868400Medicaid
MI0852210320OtherBCBS MI
WIP00297697OtherRR MEDICARE
MIP17840004Medicare PIN