Provider Demographics
NPI:1801866744
Name:WIESE, KIM KEITH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:KEITH
Last Name:WIESE
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1524 W GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4692
Mailing Address - Country:US
Mailing Address - Phone:309-512-0902
Mailing Address - Fax:309-403-0397
Practice Address - Street 1:1524 W GLEN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4692
Practice Address - Country:US
Practice Address - Phone:309-512-0902
Practice Address - Fax:094-030-3973
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2020-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085.006503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant