Provider Demographics
NPI:1508896614
Name:WISNIEWSKI, JEFFREY J (PAC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1014 SIXTH ST
Mailing Address - Street 2:STE. 103
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2381
Mailing Address - Country:US
Mailing Address - Phone:989-340-1211
Mailing Address - Fax:989-340-1214
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-7390
Practice Address - Fax:989-340-1214
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q68497Medicare UPIN