MEDICARE: STACEY A PNIEWSKI PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601005529	MI

General Provider Information

NPI Number	:	1770710998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY A PNIEWSKI PA

Provider Business Mailing Address
First Line	:	1959 E PARIS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6272
Country	:	US
Telephone Number	:	616-808-2695
Fax Number	:	616-808-2697

Provider Business Practice Location Address
First Line	:	1959 E PARIS AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6272
Country	:	US
Telephone Number	:	616-808-2695
Fax Number	:	616-808-2697

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	12/11/2014

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Directions to “ STACEY A PNIEWSKI PA” Practice Location

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