Provider Demographics
NPI:1598184731
Name:WIESE, GEORG KRISTOFER (MD)
Entity type:Individual
Prefix:
First Name:GEORG
Middle Name:KRISTOFER
Last Name:WIESE
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 1:34509 9TH AVE S STE 204
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8708
Mailing Address - Country:US
Mailing Address - Phone:253-835-5510
Mailing Address - Fax:253-835-5511
Practice Address - Street 1:34509 9TH AVE S STE 204
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8708
Practice Address - Country:US
Practice Address - Phone:253-835-5510
Practice Address - Fax:253-835-5511
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128351208600000X
WAMD61684844208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery