Provider Demographics
NPI:1275546939
Name:WIESE, WENDY A (DO)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:A
Last Name:WIESE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 BETHLEHEM PIKE
Mailing Address - Street 2:SUITE B 232
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-1111
Mailing Address - Country:US
Mailing Address - Phone:215-233-1500
Mailing Address - Fax:215-233-1015
Practice Address - Street 1:1811 BETHLEHEM PIKE
Practice Address - Street 2:SUITE B 232
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031
Practice Address - Country:US
Practice Address - Phone:215-233-1500
Practice Address - Fax:215-233-1015
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05008922-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0534254000OtherIBC
PA0017226000003Medicaid
023237 E42Medicare ID - Type Unspecified
PA0017226000003Medicaid