Provider Demographics
NPI:1730622101
Name:GWOZDZ, COLLEEN MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MICHELLE
Last Name:GWOZDZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W HIGHLAND RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357-4573
Mailing Address - Country:US
Mailing Address - Phone:248-887-5333
Mailing Address - Fax:
Practice Address - Street 1:210 W HIGHLAND RD
Practice Address - Street 2:SUITE 210
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4573
Practice Address - Country:US
Practice Address - Phone:248-887-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant