Individual
DR. KATHLEEN MARIE WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
3333 SILAS CREEK PKWY, WINSTON SALEM, NC 27103-3013
(336) 718-7597
(336) 718-7598
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(336) 718-7597
(336) 718-7598
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
2007-01475
NC
2084V0102X
Vascular Neurology Physician
2007-01475
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1457P
BCBS NC
NC
01
—
2007-01475
NC MED BOARD LICENSE
NC
05
—
5907596
—
NC
01
—
P00414192
RAILROAD MEDICARE
NC
Enumeration date
06/01/2007
Last updated
10/25/2020
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