Provider Demographics
NPI:1720578396
Name:WIEST, COLIN MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:MATTHEW
Last Name:WIEST
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-756-3107
Mailing Address - Fax:919-535-3271
Practice Address - Street 1:6015 FARRINGTON RD STE 101A
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-8154
Practice Address - Country:US
Practice Address - Phone:919-251-9378
Practice Address - Fax:919-251-9481
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist