Healthcare Provider Details

I. General information

NPI: 1205317260
Provider Name (Legal Business Name): HALLIE CHANSON WIETERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 N CHURCH ST
GREENSBORO NC
27401-1007
US

IV. Provider business mailing address

8165 WHITMORE COVE LN
CLEMMONS NC
27012-8881
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-4400
  • Fax:
Mailing address:
  • Phone: 336-782-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08304
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: