Provider Demographics
NPI:1902021553
Name:WIEMAN, ERIC ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ANDREW
Last Name:WIEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7690
Mailing Address - Fax:307-739-7644
Practice Address - Street 1:555 E BROADWAY AVE STE 229
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7690
Practice Address - Fax:307-739-7644
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10897A208600000X
KY45948208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY145089100Medicaid
KY50052510OtherPASSPORT
KY7100254290Medicaid
KYK083400Medicare PIN
KY50052510OtherPASSPORT