Provider Demographics
NPI:1760951321
Name:WIERENGA, ELIZABETH JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:WIERENGA
Suffix:
Gender:F
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 1:7883 SEARS RD
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:MI
Mailing Address - Zip Code:49246-9513
Mailing Address - Country:US
Mailing Address - Phone:517-563-2072
Mailing Address - Fax:
Practice Address - Street 1:875 LAURENCE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2966
Practice Address - Country:US
Practice Address - Phone:517-787-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010978363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant