Individual
TANYA A WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
4950 NORTON HEALTHCARE BLVD STE 208, LOUISVILLE, KY 40241-2847
(502) 614-4179
(502) 614-4450
Mailing address
PO BOX 776351, CHICAGO, IL 60677-6351
(502) 588-9490
(502) 272-5116
Taxonomy
Speciality
Code
Description
License number
State
207RP1001X
Pulmonary Disease Physician
02002644A
IN
207RP1001X
Pulmonary Disease Physician
Primary
02781
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000290297
ANTHEM
KY
05
—
200456800
—
IN
05
—
64066590
—
KY
Enumeration date
07/07/2006
Last updated
04/12/2024
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