Provider Demographics
NPI:1225774045
Name:WIESE, CHRISTIAN DOUGLAS
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:DOUGLAS
Last Name:WIESE
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 1:4409 E MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9324
Mailing Address - Country:US
Mailing Address - Phone:602-818-7845
Mailing Address - Fax:
Practice Address - Street 1:4730 E LONE MOUNTAIN RD STE 114
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-5539
Practice Address - Country:US
Practice Address - Phone:480-272-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014476225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant