Provider Demographics
NPI:1578570354
Name:WIESE, KRISTEN MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARY
Last Name:WIESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MILL ST MS M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:10085 DOUBLE R BLVD
Practice Address - Street 2:STE 102
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5931
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3900
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1578570354Medicaid
NVDC616ZMedicare PIN
NVDC616YMedicare PIN
NV1578570354Medicaid
NV102657Medicare PIN