Provider Demographics
NPI:1497715130
Name:WIERS, SUSAN GAYLE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:WIERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43750 GARFIELD RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1135
Mailing Address - Country:US
Mailing Address - Phone:586-226-6865
Mailing Address - Fax:586-226-6880
Practice Address - Street 1:35050 23 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-3606
Practice Address - Country:US
Practice Address - Phone:586-725-0477
Practice Address - Fax:586-725-8835
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704135893163WG0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-0-86-6532-0OtherBCBS PIN NUMBER
MI4378385Medicaid
MIN40180-005Medicare ID - Type UnspecifiedMEDICARE
MI4378385Medicaid