Healthcare Provider Details

I. General information

NPI: 1902893084
Provider Name (Legal Business Name): MICHELLE MARIE WUESTE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 N WOLFE AVE BLDG 3925
EDWARDS AFB CA
93524-6201
US

IV. Provider business mailing address

55 N WOLFE AVE BLDG 3925
EDWARDS AFB CA
93524-6201
US

V. Phone/Fax

Practice location:
  • Phone: 661-277-2573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA90199
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA90199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: