Individual
MR. KIM KEITH WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1524 W GLEN AVE, PEORIA, IL 61614-4692
(309) 512-0902
(094) 030-3973
Mailing address
1524 W GLEN AVE, PEORIA, IL 61614-4692
(309) 512-0902
(309) 403-0397
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085.006503
IL
Other
Enumeration date
01/24/2006
Last updated
05/19/2020
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