Provider Demographics
NPI:1295985125
Name:WIEME, LAUREN OURT (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:OURT
Last Name:WIEME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:MEREDITH
Other - Last Name:OURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-1547
Mailing Address - Country:US
Mailing Address - Phone:706-228-3125
Mailing Address - Fax:706-228-3160
Practice Address - Street 1:465 N. BELAIR RD
Practice Address - Street 2:SUITE 1B
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3189
Practice Address - Country:US
Practice Address - Phone:706-228-3125
Practice Address - Fax:706-228-3160
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant