Provider Demographics
NPI:1104958412
Name:WIETIES, WILLIAM (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WIETIES
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3011
Mailing Address - Country:US
Mailing Address - Phone:910-671-5290
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-671-5000
Practice Address - Fax:910-738-3764
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102562367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO913284816Medicaid
NC1104958412Medicaid
MO430016565Medicare PIN
MO913284816Medicaid
NCQ42666AMedicare PIN