Provider Demographics
NPI:1205317260
Name:WIETERS, HALLIE CHANSON (PA-C)
Entity type:Individual
Prefix:MISS
First Name:HALLIE
Middle Name:CHANSON
Last Name:WIETERS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:8165 WHITMORE COVE LN
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8881
Mailing Address - Country:US
Mailing Address - Phone:336-782-1405
Mailing Address - Fax:
Practice Address - Street 1:1123 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1007
Practice Address - Country:US
Practice Address - Phone:336-832-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1152394OtherNCCPA
NC0010-08304OtherNORTH CAROLINA MEDICAL BOARD