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General NPI Number Information
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NPI Number | 1629924832
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Entity Type | Individual
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Provider Name | SAMUEL BRIAN WIESE PT, DPT, SCS
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Gender | Male
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Dates
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Enumeration Date | 03/09/2026
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Last Update Date | 03/09/2026
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Provider Practice Location Address
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Address Line | 960 S MAIN ST STE H
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City | COTTONWOOD
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State | AZ
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Zip | 86326-5436
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Country | US
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Telephone | 928-852-2429
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Fax |
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Provider Business Mailing Address
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Address Line | 12679 SCOTT ST
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City | OMAHA
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State | NE
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Zip | 68142-1793
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Country | US
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Telephone | 515-783-6939
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | CP048174T
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4848
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License Number State | NE
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