Provider Demographics
NPI:1396701785
Name:WIENS, HARRY JAKE (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:JAKE
Last Name:WIENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5432 E SOUTHERN AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2772
Mailing Address - Country:US
Mailing Address - Phone:480-325-3275
Mailing Address - Fax:480-981-9123
Practice Address - Street 1:5432 E SOUTHERN AVE
Practice Address - Street 2:STE. 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2772
Practice Address - Country:US
Practice Address - Phone:480-325-3275
Practice Address - Fax:480-981-9123
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69337Medicare PIN
AZE36734Medicare UPIN