Provider Demographics
NPI:1306818299
Name:WIETERS, JAMES W (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:WIETERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 DELHI ST SUITE 300
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6320
Mailing Address - Country:US
Mailing Address - Phone:563-557-8500
Mailing Address - Fax:563-589-4050
Practice Address - Street 1:1515 DELHI ST SUITE 300
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6320
Practice Address - Country:US
Practice Address - Phone:563-557-8500
Practice Address - Fax:563-589-4050
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA054584367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43330700Medicaid
WI43330700Medicaid