Provider Demographics
NPI:1508102450
Name:WIESNER, BRADLEY A (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:WIESNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:NE
Mailing Address - Zip Code:69140-3095
Mailing Address - Country:US
Mailing Address - Phone:308-352-7200
Mailing Address - Fax:308-352-7290
Practice Address - Street 1:900 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:NE
Practice Address - Zip Code:69140-3095
Practice Address - Country:US
Practice Address - Phone:308-352-7200
Practice Address - Fax:308-352-7290
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 179376-9367500000X
NE101208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025589400Medicaid