Healthcare Provider Details

I. General information

NPI: 1629220488
Provider Name (Legal Business Name): MR. RICHARD LEE WIESEMANN II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 104
COEUR D ALENE ID
83814-2668
US

IV. Provider business mailing address

1555 LIBERTY LN STE C
MISSOULA MT
59808-2001
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-0621
  • Fax:
Mailing address:
  • Phone: 406-728-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-2733
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMT 543
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: