NPIMap

Individual provider Active NPI

Carolyn Marie Wiese, PA

  • Physician Assistant
  • Petoskey, MI
National Provider Identifier
1235130576
Registry record updated Aug 31, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
5601003704 Issued in MI
Practice address
3890 Charlevoix Rd Ste 307
Petoskey, MI 49770-9719
Phone
(231) 674-3834
NPI assigned
Aug 9, 2005
Last updated
Aug 31, 2026By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 31, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 5601003704 MI Primary
Medical Physician Assistant 363AM0700X PA001143 ME

Addresses

Primary practice location

3890 Charlevoix Rd Ste 307
Petoskey, MI 49770-9719

Mailing address

743 E Beltline Ave NE
Grand Rapids, MI 49525-6045
Phone (616) 320-0096

Other identifiers 1

IdentifierTypeStateIssuer
1235130576MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050527000355 MI Practitioner - Physician Assistant 7416999628 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Petoskey Family Medicine, P.C.Group PAC ID 8022150556, 5 clinicians

Practice addresses (Care Compare)

1890 S US Hwy 131 Unit 3
Petoskey, MI 49770-8344

1890 US Hwy 131
Unit 3
Petoskey, MI 49770-8344
Phone (231) 487-6000

1890 US Hwy 131 S 3
Petoskey, MI 49770-8344

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA001143MEMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Petoskey Family Medicine P.C. Past Accepting new patients
Beacon Dowagiac Inc Past Accepting new patients
Battle Creek Emergency Physicians, PC Physician Assistant Past Accepting new patients
Dr Fred PLLC Medical PastSince May 26, 2024 Accepting new patients

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123545600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1788134400000",
    "number": "1235130576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "743 E BELTLINE AVE NE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495256045",
            "telephone_number": "616-320-0096"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3890 CHARLEVOIX RD STE 307",
            "city": "PETOSKEY",
            "state": "MI",
            "postal_code": "497709719",
            "telephone_number": "231-674-3834"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIESE",
        "first_name": "CAROLYN",
        "middle_name": "MARIE",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-08-09",
        "last_updated": "2026-08-31",
        "certification_date": "2026-08-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601003704",
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "ME",
            "license": "PA001143",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1235130576",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Petoskey, MI

Sources for this page

Verify at the official NPI Registry.