Healthcare Provider Details

I. General information

NPI: 1528853868
Provider Name (Legal Business Name): DAVID WIEBE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N SANTA ANA AVE
MODESTO CA
95354-1552
US

IV. Provider business mailing address

315 N SANTA ANA AVE
MODESTO CA
95354-1552
US

V. Phone/Fax

Practice location:
  • Phone: 831-295-0960
  • Fax:
Mailing address:
  • Phone: 831-295-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number550374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: