Basic Information
| Provider Information | |||||||||
| NPI: | 1568426468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIESNER | ||||||||
| FirstName: | J. | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30077 | ||||||||
| Address2: | DEPT 305 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772438416 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 S CIMARRON RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024770772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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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 | 2085R0202X | 3328 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200290101 | 05 | NV | MEDICAID | NV1963 | 01 | NV | BCBS OF NV | OTHER | NV4878 | 01 | NV | BCBS OF NV | OTHER | POO284395 | 01 | NV | RAILROAD MEDICARE | OTHER |