Healthcare Provider Details

I. General information

NPI: 1174335913
Provider Name (Legal Business Name): IAN MATTHEW WIERSMA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

IV. Provider business mailing address

217 4TH ST NW
ORANGE CITY IA
51041-1322
US

V. Phone/Fax

Practice location:
  • Phone: 520-694-0111
  • Fax:
Mailing address:
  • Phone: 616-240-4710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number12034
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: