Provider Demographics
NPI:1154855021
Name:MANGUERRA-CASIANO, WIEN (DO)
Entity Type:Individual
Prefix:DR
First Name:WIEN
Middle Name:
Last Name:MANGUERRA-CASIANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:WIEN
Other - Middle Name:
Other - Last Name:MANGUERRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:42051 PEPPERBUSH PL
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11213 LEE HWY STE H
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5698
Practice Address - Country:US
Practice Address - Phone:703-372-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty