Provider Demographics
NPI:1326493073
Name:WIESNER, MICAH (PA)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:712A SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5128
Practice Address - Country:US
Practice Address - Phone:620-275-1766
Practice Address - Fax:620-275-4729
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant