Provider Demographics
NPI:1457306987
Name:PIESIK, CAROL LYNN (PA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:PIESIK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:110 N ELM AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3571
Practice Address - Country:US
Practice Address - Phone:517-788-6760
Practice Address - Fax:517-788-3029
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC37626048Medicare PIN
MIS71153Medicare UPIN
MIN79450009Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MIN88100019Medicare PIN