Provider Demographics
NPI:1225736820
Name:WIERING, GARY JOHN
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:WIERING
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 1:402 DANEBOD DRIVE APT 2
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178
Mailing Address - Country:US
Mailing Address - Phone:507-276-9274
Mailing Address - Fax:
Practice Address - Street 1:611 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1301
Practice Address - Country:US
Practice Address - Phone:605-997-2481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100882225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist