Provider Demographics
NPI:1417273509
Name:WIARDA, CHRISTY
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:WIARDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W 4TH ST STE 8
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3700
Mailing Address - Country:US
Mailing Address - Phone:605-655-1200
Mailing Address - Fax:
Practice Address - Street 1:409 SUMMIT ST STE 2600
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3746
Practice Address - Country:US
Practice Address - Phone:605-655-1200
Practice Address - Fax:605-655-1210
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD217213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program