Healthcare Provider Details

I. General information

NPI: 1235232125
Provider Name (Legal Business Name): MICHELLE WIEMAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N WASHINGTON STREET
VIBORG SD
57070-0368
US

IV. Provider business mailing address

44760 273RD ST
MARION SD
57043-5501
US

V. Phone/Fax

Practice location:
  • Phone: 605-326-5161
  • Fax: 605-326-5734
Mailing address:
  • Phone: 605-297-4240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0044
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5833640
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: