Provider Demographics
NPI:1174069108
Name:WIENER, GEORGIA W (PA-C)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:W
Last Name:WIENER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1333
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1333
Mailing Address - Country:US
Mailing Address - Phone:703-331-9749
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR STE 180
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-3633
Practice Address - Fax:970-668-4406
Is Sole Proprietor?:No
Enumeration Date:2017-01-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant