Individual
DR. DEAN S. WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
403 BLACK HILLS LN SW STE A, OLYMPIA, WA 98502-8600
(360) 705-0421
(360) 705-0493
Mailing address
1401 MARVIN RD NE, SUITE 307 PMB 266, LACEY, WA 98516-5709
(360) 491-5055
(360) 491-5890
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
MD00030693
WA
207R00000X
Internal Medicine Physician
Primary
MD00030693
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1810019
—
WA
01
—
44789
L&I WORKERS COMP
WA
01
—
5007947
GROUP HEALTH
WA
01
—
953646046
TAX ID
WA
01
—
MD00030693
WA STATE LICENSE
WA
01
—
WI0066
BLUE CROSS/BLUE SHIELD
WA
Enumeration date
07/11/2006
Last updated
01/13/2010
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