Provider Demographics
NPI:1942707005
Name:WIESE, KRISTA SHAW (MD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:SHAW
Last Name:WIESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:ELIZABETH
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5600 S QUEBEC ST STE 312A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2208
Mailing Address - Country:US
Mailing Address - Phone:303-436-2727
Mailing Address - Fax:
Practice Address - Street 1:111 6TH ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:CO
Practice Address - Zip Code:80821-2002
Practice Address - Country:US
Practice Address - Phone:719-743-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0065476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine