Provider Demographics
NPI:1689615791
Name:MEREDITH, WENDY SUE (PA C)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:SUE
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:SUE
Other - Last Name:CHUBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:2256 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4655
Mailing Address - Country:US
Mailing Address - Phone:810-733-8041
Mailing Address - Fax:810-733-0926
Practice Address - Street 1:2303 STONE BRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5407
Practice Address - Country:US
Practice Address - Phone:810-733-8041
Practice Address - Fax:810-733-0926
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02090Medicare UPIN
MI0N3510Medicare PIN