Healthcare Provider Details

I. General information

NPI: 1720305592
Provider Name (Legal Business Name): GREGORY JAMES NIEDZWIECKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE C/O EMERGENCY DEPARTMENT
LANSING MI
48912-1811
US

IV. Provider business mailing address

1215 E MICHIGAN AVE C/O EMERGENCY DEPARTMENT
LANSING MI
48912-1811
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 616-364-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number3202006021
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005718
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: