Healthcare Provider Details

I. General information

NPI: 1144782384
Provider Name (Legal Business Name): CHRISTOPHER HOUSTON WIEDLE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

10924 CHATHAM RIDGE WAY
SPOTSYLVANIA VA
22551-4683
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101277868
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: