Provider Demographics
NPI:1881023190
Name:WIAND, JACQUELINE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:WIAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:HIETSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:
Practice Address - Street 1:40 W WELLSBORO ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933-1411
Practice Address - Country:US
Practice Address - Phone:570-662-1945
Practice Address - Fax:570-724-3970
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA356014FEMMedicare PIN