Provider Demographics
NPI:1316188220
Name:WIENS, NATHAN JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JACOB
Last Name:WIENS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:VERADALE
Mailing Address - State:WA
Mailing Address - Zip Code:99037-0808
Mailing Address - Country:US
Mailing Address - Phone:509-363-3100
Mailing Address - Fax:509-363-0300
Practice Address - Street 1:510 E HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1206
Practice Address - Country:US
Practice Address - Phone:509-363-3100
Practice Address - Fax:509-363-0300
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60525567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant