Provider Demographics
NPI:1831195361
Name:WIERSEMA, GREGORY N (MST-CCC/A)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:N
Last Name:WIERSEMA
Suffix:
Gender:M
Credentials:MST-CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5303
Mailing Address - Country:US
Mailing Address - Phone:920-923-4678
Mailing Address - Fax:920-923-4678
Practice Address - Street 1:221 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5303
Practice Address - Country:US
Practice Address - Phone:920-923-4678
Practice Address - Fax:920-923-4678
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55-156231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41105900Medicaid
WI85011Medicare ID - Type Unspecified