Provider Demographics
NPI:1871705533
Name:WIESE, TARA YVONNE
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:YVONNE
Last Name:WIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CLARKS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-2611
Mailing Address - Country:US
Mailing Address - Phone:518-477-4484
Mailing Address - Fax:
Practice Address - Street 1:68 CLARKS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:NASSAU
Practice Address - State:NY
Practice Address - Zip Code:12123-2611
Practice Address - Country:US
Practice Address - Phone:518-477-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018451-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist