Provider Demographics
NPI:1285956367
Name:DEAN S WIESE MD PS
Entity type:Organization
Organization Name:DEAN S WIESE MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-705-0421
Mailing Address - Street 1:403 BLACK HILLS LN SW STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8600
Mailing Address - Country:US
Mailing Address - Phone:360-705-0421
Mailing Address - Fax:
Practice Address - Street 1:403 BLACK HILLS LN SW STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8600
Practice Address - Country:US
Practice Address - Phone:360-705-0421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA30693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty