Provider Demographics
NPI:1407865868
Name:WIESE, MEGAN SK (MD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:SK
Last Name:WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 MESQUITE AVE UNIT 106
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6897
Mailing Address - Country:US
Mailing Address - Phone:928-854-6249
Mailing Address - Fax:928-854-6301
Practice Address - Street 1:2130 MESQUITE AVE UNIT 106
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6897
Practice Address - Country:US
Practice Address - Phone:928-854-6249
Practice Address - Fax:928-854-6301
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29168207V00000X
CAA67033207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0735830OtherBCBS
AZ577091Medicaid
H33776Medicare UPIN
75718Medicare ID - Type Unspecified