Provider Demographics
NPI:1881183747
Name:WIESELER, CARISSA (MD)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:WIESELER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14441 DUPONT CT STE 304
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2107
Mailing Address - Country:US
Mailing Address - Phone:402-597-8775
Mailing Address - Fax:
Practice Address - Street 1:14441 DUPONT CT STE 304
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2107
Practice Address - Country:US
Practice Address - Phone:402-597-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN731262085R0202X
FLTRN281562085R0202X
NE362212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology