Healthcare Provider Details

I. General information

NPI: 1255486080
Provider Name (Legal Business Name): WILLIAM EDWIN GIESE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKINGS DR BOX 1201
SAINT LOUIS MO
63130-4862
US

IV. Provider business mailing address

10837 LEEBUR DR
SAINT LOUIS MO
63128-1532
US

V. Phone/Fax

Practice location:
  • Phone: 314-935-6666
  • Fax:
Mailing address:
  • Phone: 314-849-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: