Provider Demographics
NPI:1184297657
Name:WIERSEMA, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WIERSEMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-1925
Mailing Address - Country:US
Mailing Address - Phone:720-201-8831
Mailing Address - Fax:
Practice Address - Street 1:3855 JULIAN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1925
Practice Address - Country:US
Practice Address - Phone:720-201-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001912171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist