Provider Demographics
NPI:1053562504
Name:WIESBAUER, ANNA CARRENINA (PT)
Entity type:Individual
Prefix:MISS
First Name:ANNA
Middle Name:CARRENINA
Last Name:WIESBAUER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ANNA
Other - Middle Name:CARRENINA
Other - Last Name:GUEVARRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25062 LIND COURT
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105
Mailing Address - Country:US
Mailing Address - Phone:571-481-0241
Mailing Address - Fax:
Practice Address - Street 1:25062 LIND COURT
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105
Practice Address - Country:US
Practice Address - Phone:571-481-0241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082377225100000X
MD023257225100000X
VA2305207343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist