Provider Demographics
NPI:1740848670
Name:WIER, KOA
Entity type:Individual
Prefix:
First Name:KOA
Middle Name:
Last Name:WIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 AIRWAY AVE STE G1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4624
Mailing Address - Country:US
Mailing Address - Phone:714-545-5550
Mailing Address - Fax:
Practice Address - Street 1:999 N TUSTIN AVE STE G1
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3528
Practice Address - Country:US
Practice Address - Phone:714-545-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health