Provider Demographics
NPI:1770801375
Name:GIETZEN, LINDSAY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:NICOLE
Last Name:GIETZEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:NICOLE
Other - Last Name:KURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:19615 GALLAHAD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1766
Mailing Address - Country:US
Mailing Address - Phone:586-329-3203
Mailing Address - Fax:
Practice Address - Street 1:2004 HAZEL ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6807
Practice Address - Country:US
Practice Address - Phone:248-723-2477
Practice Address - Fax:248-681-3209
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant