Provider Demographics
NPI:1720305592
Name:NIEDZWIECKI, GREGORY JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JAMES
Last Name:NIEDZWIECKI
Suffix:
Gender:M
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 1:1215 E MICHIGAN AVE
Mailing Address - Street 2:C/O EMERGENCY DEPARTMENT
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1811
Mailing Address - Country:US
Mailing Address - Phone:616-364-1000
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:C/O EMERGENCY DEPARTMENT
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3202006021146M00000X
MI5601005718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate