Individual
MS. MARY JO P WIEMILLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
945 N 12TH ST, MILWAUKEE, WI 53233-1305
(414) 219-7880
Mailing address
945 N 12TH ST, MILWAUKEE, WI 53233-1305
(414) 219-7880
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
1621
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
006806261B
HUMANA
—
05
—
41975200
—
WI
Enumeration date
05/22/2006
Last updated
12/29/2021
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