Individual
CAROLYN MARIE WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2390 MITCHELL PARK DR STE D, PETOSKEY, MI 49770
(231) 487-7200
(231) 487-7188
Mailing address
2390 MITCHELL PARK DR STE D, PETOSKEY, MI 49770-8965
(231) 487-7200
(231) 487-7188
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601003704
MI
363AM0700X
Medical Physician Assistant
PA001143
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1235130576
—
MI
Enumeration date
08/09/2005
Last updated
06/12/2018
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