1003978610 NPI number — MRS. MAUREEN L WIESE C.PED

Table of content: MRS. MAUREEN L WIESE C.PED (NPI 1003978610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003978610 NPI number — MRS. MAUREEN L WIESE C.PED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIESE
Provider First Name:
MAUREEN
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
C.PED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003978610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11211 SE 82ND, AVE
Provider Second Line Business Mailing Address:
STE. D
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-653-8700
Provider Business Mailing Address Fax Number:
503-653-8739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11211 SE 82ND, AVE
Provider Second Line Business Practice Location Address:
STE. D
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-653-8700
Provider Business Practice Location Address Fax Number:
503-653-8739
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 229276 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com