Basic Information
| Provider Information | |||||||||
| NPI: | 1376960146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIERCK | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9097 E DESERT COVE AVE | ||||||||
| Address2: | STE 110 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805514961 | ||||||||
| FaxNumber: | 4808600356 | ||||||||
| Practice Location | |||||||||
| Address1: | 16838 E PALISADES BLVD | ||||||||
| Address2: | BLDG B-121 | ||||||||
| City: | FOUNTAIN HILLS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852683786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808372595 | ||||||||
| FaxNumber: | 4808372773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2014 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5683 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.