=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528925971
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN ROOTS MEDICAL ASSOCIATES P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2026
-----------------------------------------------------
Last Update Date | 01/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1396 DOUGLAS DR STE 22C
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49696-8981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-440-9956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1396 DOUGLAS DR STE 22C
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49696-8981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-440-9956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. HANNAH WILSON
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 231-440-9956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------