Provider Demographics
NPI:1669636460
Name:WIEWIORSKI, MICHAEL J (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WIEWIORSKI
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10810 MALLARD CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9786
Practice Address - Country:US
Practice Address - Phone:704-510-8000
Practice Address - Fax:704-510-8006
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012796363A00000X
NC0010-03610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000530695001OtherBLUE CROSS WNY
NY9515265OtherINDEPENDENT HEALTH
NY9515265OtherINDEPENDENT HEALTH