MEDICARE: LISA WIENER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	836535	CA

General Provider Information

NPI Number	:	1518026582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA WIENER

Provider Business Mailing Address
First Line	:	500 CROWN POINT CIR
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-9561
Country	:	US
Telephone Number	:	530-273-5440
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 CROWN POINT CIR
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-9561
Country	:	US
Telephone Number	:	530-273-5440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	03/30/2013

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