Provider Demographics
NPI:1164877205
Name:WIES, JOSHUA TOBIN
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TOBIN
Last Name:WIES
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 1:1501 SULGRAVE AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3651
Mailing Address - Country:US
Mailing Address - Phone:410-913-9829
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE STE 307
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3651
Practice Address - Country:US
Practice Address - Phone:410-913-9829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist