Healthcare Provider Details

I. General information

NPI: 1174069108
Provider Name (Legal Business Name): GEORGIA W WIENER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2017
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 PEAK ONE DR STE 180
FRISCO CO
80443-5948
US

IV. Provider business mailing address

2472 PATTERSON RD UNIT 8
GRAND JUNCTION CO
81505-1100
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-3633
  • Fax: 970-668-4406
Mailing address:
  • Phone: 970-241-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004893
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: