Healthcare Provider Details

I. General information

NPI: 1861019945
Provider Name (Legal Business Name): MICHAEL WIELAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 35TH AVE
MOLINE IL
61265-6176
US

IV. Provider business mailing address

612 35TH AVE
MOLINE IL
61265-6176
US

V. Phone/Fax

Practice location:
  • Phone: 309-788-0014
  • Fax: 309-623-4638
Mailing address:
  • Phone: 309-788-0014
  • Fax: 309-623-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: