Provider Demographics
NPI:1386637668
Name:WIESSNER, HARRY WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:WALTER
Last Name:WIESSNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E ALDER ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2073
Mailing Address - Country:US
Mailing Address - Phone:509-527-3937
Mailing Address - Fax:509-529-4750
Practice Address - Street 1:614 E ALDER ST
Practice Address - Street 2:SUITE #1
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2073
Practice Address - Country:US
Practice Address - Phone:509-527-3937
Practice Address - Fax:509-529-4750
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2300036Medicaid
WAG8900643OtherPTAN
WAG8900643OtherPTAN
WA2300036Medicaid