Provider Demographics
NPI:1174335913
Name:WIERSMA, IAN MATTHEW
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:WIERSMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1322
Mailing Address - Country:US
Mailing Address - Phone:616-240-4710
Mailing Address - Fax:
Practice Address - Street 1:217 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-1322
Practice Address - Country:US
Practice Address - Phone:616-240-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant