Basic Information
| Provider Information | |||||||||
| NPI: | 1245549153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIESE | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1449 HIGHWAY 6 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774785145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817686730 | ||||||||
| FaxNumber: | 2817686766 | ||||||||
| Practice Location | |||||||||
| Address1: | 1449 HIGHWAY 6 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774785145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817686730 | ||||||||
| FaxNumber: | 2817686766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 09/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | CNIM 1606 | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.