Provider Demographics
NPI:1669801825
Name:WIESNER, VICTORIA A (CRNP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:WIESNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 BUFFALO RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-2391
Mailing Address - Country:US
Mailing Address - Phone:814-877-7686
Mailing Address - Fax:814-877-7692
Practice Address - Street 1:5241 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2391
Practice Address - Country:US
Practice Address - Phone:814-877-7686
Practice Address - Fax:814-877-7692
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013316363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031007550001Medicaid