Provider Demographics
NPI:1376317339
Name:WACLAWSKI, PAYTON LANE
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:LANE
Last Name:WACLAWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7581 PINE PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9131
Mailing Address - Country:US
Mailing Address - Phone:616-304-6629
Mailing Address - Fax:
Practice Address - Street 1:828 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2056
Practice Address - Country:US
Practice Address - Phone:616-754-7186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant