Provider Demographics
NPI:1790712057
Name:WIESEL, CHARLES D (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:WIESEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 E SUNRISE DR STE 121
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-4324
Mailing Address - Country:US
Mailing Address - Phone:520-209-7000
Mailing Address - Fax:520-209-7010
Practice Address - Street 1:4001 E SUNRISE DR STE 121
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-4324
Practice Address - Country:US
Practice Address - Phone:520-209-7000
Practice Address - Fax:520-209-7010
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS81819Medicare UPIN
AZZ104410Medicare PIN
AZZ104411Medicare PIN