Provider Demographics
NPI:1639493372
Name:WIESNER, ERIN KATHLEEN (PA)
Entity Type:Individual
Prefix:MS
First Name:ERIN
Middle Name:KATHLEEN
Last Name:WIESNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15945 CLAYTON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2490
Mailing Address - Country:US
Mailing Address - Phone:636-256-5000
Mailing Address - Fax:
Practice Address - Street 1:15945 CLAYTON RD STE 120
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2490
Practice Address - Country:US
Practice Address - Phone:636-256-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010039476363A00000X
KS15-01375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220041145Medicaid