Healthcare Provider Details

I. General information

NPI: 1265410286
Provider Name (Legal Business Name): DR. DAVID CHARLES WIESNER
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 WYCLIFF RD SUITE 103
RALEIGH NC
27607-3073
US

IV. Provider business mailing address

8290 165TH AVE NE
REDMOND WA
98052-3948
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-4060
  • Fax: 919-782-0906
Mailing address:
  • Phone: 425-869-2644
  • Fax: 425-867-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60405036
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2039
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: