Provider Demographics
NPI:1881112449
Name:WIANECKI, TESS (PA)
Entity type:Individual
Prefix:
First Name:TESS
Middle Name:
Last Name:WIANECKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-2505
Mailing Address - Country:US
Mailing Address - Phone:805-202-8245
Mailing Address - Fax:805-202-8117
Practice Address - Street 1:860 OAK PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1800
Practice Address - Country:US
Practice Address - Phone:805-202-8245
Practice Address - Fax:805-202-8117
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55021363A00000X, 363A00000X
CA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical