Provider Demographics
NPI:1508884669
Name:WISNIEWSKI, CARY D (PA-C)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:D
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GREEN ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-995-3764
Mailing Address - Fax:208-475-9028
Practice Address - Street 1:2000 GREEN ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-995-3764
Practice Address - Fax:208-475-9028
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120045Medicare PIN