Provider Demographics
NPI:1942288501
Name:WESSELS, MIA R (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:R
Last Name:WESSELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-1777
Mailing Address - Fax:276-258-1776
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 101B
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-1777
Practice Address - Fax:276-258-1776
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101040882207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005997445Medicaid
VA039404OtherANTHEM
TN0101OtherJOHN DEERE
B08818Medicare UPIN
VAVVJ766AMedicare PIN