Healthcare Provider Details

I. General information

NPI: 1720212954
Provider Name (Legal Business Name): WAYNE WIEKHORST DVM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48410 N BLACK CANYON HWY
NEW RIVER AZ
85087-6911
US

IV. Provider business mailing address

48410 N BLACK CANYON HWY
NEW RIVER AZ
85087-6911
US

V. Phone/Fax

Practice location:
  • Phone: 623-465-9488
  • Fax: 623-465-5922
Mailing address:
  • Phone: 623-465-9488
  • Fax: 623-465-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License NumberAZ970
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: