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General NPI Number Information
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NPI Number | 1104469055
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Entity Type | Individual
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Provider Name | AVA MARIE WIEDEMANN PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/23/2019
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Last Update Date | 11/08/2019
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Provider Practice Location Address
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Address Line | 9665 CHESAPEAKE DR STE 350
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City | SAN DIEGO
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State | CA
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Zip | 92123-1352
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Country | US
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Telephone | 877-260-2261
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Fax |
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Provider Business Mailing Address
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Address Line | 2131 E GRETTA PL
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City | PHOENIX
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State | AZ
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Zip | 85022-3436
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Country | US
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Telephone | 602-793-6456
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA57411
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License Number State | CA
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