Provider Demographics
NPI:1871500546
Name:WIENCKE, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:WIENCKE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2025 SLOAN PL
Mailing Address - Street 2:STE 35
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2007
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:1050 LARPENTEUR AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-6556
Practice Address - Country:US
Practice Address - Phone:651-487-2831
Practice Address - Fax:651-487-1705
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN17420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN397873700Medicaid
A95667Medicare UPIN