Provider Demographics
NPI:1720134786
Name:WESENBERG, DAWN E (PA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:E
Last Name:WESENBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:E
Other - Last Name:NEHLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4328 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1077
Mailing Address - Country:US
Mailing Address - Phone:517-764-3609
Mailing Address - Fax:517-764-3659
Practice Address - Street 1:4328 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254
Practice Address - Country:US
Practice Address - Phone:517-764-3609
Practice Address - Fax:517-764-3659
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1592-023363A00000X
MI5601006290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4190800Medicaid
MI1720134786Medicaid
MI1720134786Medicaid