Healthcare Provider Details

I. General information

NPI: 1801718788
Provider Name (Legal Business Name): KEITH THOMAS WIETHAUPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7827 TOWN SQUARE AVE STE 104
O FALLON MO
63368-7199
US

IV. Provider business mailing address

7827 TOWN SQUARE AVE STE 104
O FALLON MO
63368-7199
US

V. Phone/Fax

Practice location:
  • Phone: 636-734-0386
  • Fax: 636-352-4173
Mailing address:
  • Phone: 636-734-0386
  • Fax: 636-352-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number147974
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: