Healthcare Provider Details

I. General information

NPI: 1235130576
Provider Name (Legal Business Name): CAROLYN MARIE WIESE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 CHARLEVOIX RD STE 307
PETOSKEY MI
49770-9719
US

IV. Provider business mailing address

743 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-6045
US

V. Phone/Fax

Practice location:
  • Phone: 231-674-3834
  • Fax:
Mailing address:
  • Phone: 616-320-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003704
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA001143
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: