Provider Demographics
NPI:1811191752
Name:HUNDRIESER, JEANINE NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:NICOLE
Last Name:HUNDRIESER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:18223 E 10 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5821
Mailing Address - Country:US
Mailing Address - Phone:586-778-5880
Mailing Address - Fax:586-778-4362
Practice Address - Street 1:18223 E 10 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5821
Practice Address - Country:US
Practice Address - Phone:586-778-5880
Practice Address - Fax:586-778-4362
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005042OtherLICENSE