Basic Information
| Provider Information | |||||||||
| NPI: | 1962031765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESELY | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 MICHIGAN ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163911909 | ||||||||
| FaxNumber: | 6163918612 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 MICHIGAN ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163911909 | ||||||||
| FaxNumber: | 6163918612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.