Basic Information
| Provider Information | |||||||||
| NPI: | 1992725949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIESE | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 605 | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934650605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054341375 | ||||||||
| FaxNumber: | 8054341716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 LAS TABLAS RD | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934659704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054343500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207L00000X | G53163 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ46801Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER | GR0065000 | 05 | CA | MEDICAID |