Healthcare Provider Details

I. General information

NPI: 1407865868
Provider Name (Legal Business Name): MEGAN SK WIESE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 MESQUITE AVE UNIT 106
LAKE HAVASU CITY AZ
86403-6897
US

IV. Provider business mailing address

2130 MESQUITE AVE UNIT 106
LAKE HAVASU CITY AZ
86403-6897
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-6249
  • Fax: 928-854-6301
Mailing address:
  • Phone: 928-854-6249
  • Fax: 928-854-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number29168
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: