Healthcare Provider Details

I. General information

NPI: 1508896614
Provider Name (Legal Business Name): JEFFREY J. WISNIEWSKI P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W CHISHOLM ST
ALPENA MI
49707-1401
US

IV. Provider business mailing address

1014 SIXTH ST STE. 103
TRAVERSE CITY MI
49684-2381
US

V. Phone/Fax

Practice location:
  • Phone: 989-356-7390
  • Fax: 989-340-1214
Mailing address:
  • Phone: 989-340-1211
  • Fax: 989-340-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003807
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: