Provider Demographics
NPI:1588043475
Name:WIESELER, ALIVIA
Entity Type:Individual
Prefix:
First Name:ALIVIA
Middle Name:
Last Name:WIESELER
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 1:8415 N PIMA RD
Mailing Address - Street 2:STE 212
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4485
Mailing Address - Country:US
Mailing Address - Phone:520-426-1512
Mailing Address - Fax:520-426-1750
Practice Address - Street 1:1637 E MONUMENT PLAZA CIR STE 1
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5639
Practice Address - Country:US
Practice Address - Phone:520-426-1512
Practice Address - Fax:520-426-1750
Is Sole Proprietor?:No
Enumeration Date:2015-05-25
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6051363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSS#