Provider Demographics
NPI:1073535977
Name:WIESE, KRISTINE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2182
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-0008
Mailing Address - Country:US
Mailing Address - Phone:612-670-1321
Mailing Address - Fax:
Practice Address - Street 1:2277 HIGHWAY 36 W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3804
Practice Address - Country:US
Practice Address - Phone:612-255-0628
Practice Address - Fax:612-255-0647
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN393602084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG-67526Medicare UPIN