1417123399 NPI number — TAMI RAY WIELAND PA

Table of content: TAMI RAY WIELAND PA (NPI 1417123399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417123399 NPI number — TAMI RAY WIELAND PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIELAND
Provider First Name:
TAMI
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1417123399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 S. FM 1346
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
LAVERNIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-253-1216
Provider Business Mailing Address Fax Number:
830-253-1221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 S. FM 1346
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LA VERNIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-531-2168
Provider Business Practice Location Address Fax Number:
830-253-1221
Provider Enumeration Date:
05/01/2008

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: 363A00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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