Provider Demographics
NPI:1467781021
Name:WIESE, TRACEY L (ANP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:L
Last Name:WIESE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 SESAME ST
Mailing Address - Street 2:STE 1B
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6657
Mailing Address - Country:US
Mailing Address - Phone:907-334-1000
Mailing Address - Fax:907-334-8080
Practice Address - Street 1:741 SESAME ST
Practice Address - Street 2:STE 1B
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6657
Practice Address - Country:US
Practice Address - Phone:907-334-1000
Practice Address - Fax:907-334-8080
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0101Medicaid
AKMPG0335Medicaid