Healthcare Provider Details

I. General information

NPI: 1891021366
Provider Name (Legal Business Name): GERI ANN WIELAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GERI ANN EDMONDS PA-C

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 RIDGEWOOD DR
MIDLAND MI
48642-5836
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 989-254-6427
  • Fax: 989-607-1314
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005609
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002045
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: