Healthcare Provider Details

I. General information

NPI: 1699935510
Provider Name (Legal Business Name): ANDREA L WIENS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 02/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W 11TH ST INDIANA UNIVERSITY HEATLH, DEPARTMENT OF PATHOLOGY
INDIANAPOLIS IN
46202-4108
US

IV. Provider business mailing address

350 W 11TH ST INDIANA UNIVERSITY HEATLH, DEPARTMENT OF PATHOLOGY
INDIANAPOLIS IN
46202-4108
US

V. Phone/Fax

Practice location:
  • Phone: 765-717-5550
  • Fax: 317-491-6419
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number02003724A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: