Provider Demographics
NPI:1417907874
Name:WAINSCOTT, TERESA L (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:WAINSCOTT
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 MICHIGAN ST NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2537
Practice Address - Country:US
Practice Address - Phone:616-459-7258
Practice Address - Fax:616-459-5215
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001788OtherSTATE LICENSE
P00002711Medicare ID - Type UnspecifiedRAILROAD MEDICARE
0N24810Medicare PIN
MW0851647OtherDEA
R47114Medicare UPIN