Provider Demographics
NPI:1003978610
Name:WIESE, MAUREEN L (CPED)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:L
Last Name:WIESE
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 SE 82ND, AVE
Mailing Address - Street 2:STE. D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-653-8700
Mailing Address - Fax:503-653-8739
Practice Address - Street 1:11211 SE 82ND, AVE
Practice Address - Street 2:STE. D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-653-8700
Practice Address - Fax:503-653-8739
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR229276Medicaid
OR4075700001Medicare NSC