Provider Demographics
NPI:1710616040
Name:WIESE, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:WIESE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2347 E GALA ST STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4881
Practice Address - Country:US
Practice Address - Phone:208-345-3530
Practice Address - Fax:208-381-5080
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant