Provider Demographics
NPI:1023048055
Name:VISICH, DIANE M (PA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:VISICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 994
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-0994
Mailing Address - Country:US
Mailing Address - Phone:989-775-7641
Mailing Address - Fax:989-775-6472
Practice Address - Street 1:211 S CRAPO ST
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2961
Practice Address - Country:US
Practice Address - Phone:989-775-3823
Practice Address - Fax:989-773-5061
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0853701290OtherBCBSM
MIM17400013Medicare PIN
MI0853701290OtherBCBSM