Provider Demographics
NPI:1700376043
Name:WIERSMA, RICHARD H JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:H
Last Name:WIERSMA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 SUNRISE TER
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-5427
Mailing Address - Country:US
Mailing Address - Phone:775-217-9472
Mailing Address - Fax:
Practice Address - Street 1:903 TAYLOR PL
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-6806
Practice Address - Country:US
Practice Address - Phone:775-423-3392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty