Provider Demographics
NPI:1295890804
Name:WIESELER, JON M (PT)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:M
Last Name:WIESELER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SOUTH COTTONWOOD
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6138
Mailing Address - Country:US
Mailing Address - Phone:308-532-5480
Mailing Address - Fax:308-532-5480
Practice Address - Street 1:1001 SOUTH COTTONWOOD
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6138
Practice Address - Country:US
Practice Address - Phone:308-532-5480
Practice Address - Fax:308-532-5480
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024973400Medicaid
NE39616OtherBCBS
NECK7267OtherRR MEDICARE
NE10024973400Medicaid
NE276293Medicare ID - Type Unspecified