Provider Demographics
NPI:1992737886
Name:WIESE, TANYA A (DO)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:A
Last Name:WIESE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4950 NORTON HEALTHCARE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2847
Practice Address - Country:US
Practice Address - Phone:502-614-4179
Practice Address - Fax:502-614-4450
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002644A207RP1001X
KY02781207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000290297OtherANTHEM
IN200456800Medicaid
KY64066590Medicaid
KY0555511Medicare ID - Type Unspecified
KY000000290297OtherANTHEM
KYH82818Medicare UPIN
IN200456800Medicaid