Provider Demographics
NPI:1619996691
Name:WIESKAMP, STEPHEN THEODORE (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:THEODORE
Last Name:WIESKAMP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:2109 CEDARWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-2670
Practice Address - Country:US
Practice Address - Phone:563-288-6787
Practice Address - Fax:563-288-6719
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0263731Medicaid
IA349984700OtherUS DEPT OF LABOR WORK COM
IA49799OtherWELLMARK
IA49799OtherWELLMARK