Provider Demographics
NPI:1104896836
Name:WIESEN, ANDREW RICHARD (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RICHARD
Last Name:WIESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13501 152ND STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9244
Mailing Address - Country:US
Mailing Address - Phone:253-968-4475
Mailing Address - Fax:
Practice Address - Street 1:MAMC
Practice Address - Street 2:ATTN: MCHJ-PV (LTC WIESEN)
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-4475
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33777207R00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine