Provider Demographics
NPI:1225298466
Name:WIENKERS, MARIJO L (MD)
Entity Type:Individual
Prefix:
First Name:MARIJO
Middle Name:L
Last Name:WIENKERS
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 1:15705 E OCOTILLO DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-5318
Mailing Address - Country:US
Mailing Address - Phone:575-649-4527
Mailing Address - Fax:
Practice Address - Street 1:15705 E OCOTILLO DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-5318
Practice Address - Country:US
Practice Address - Phone:575-649-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ64251207L00000X
WAMD60284902207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022155Medicaid
WAG8919477Medicare UPIN