Provider Demographics
NPI:1689628703
Name:WIEMILLER, MARY JO P (PA)
Entity type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:P
Last Name:WIEMILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:MATZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:945 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1305
Mailing Address - Country:US
Mailing Address - Phone:414-219-7880
Mailing Address - Fax:
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1621363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
006806261BOtherHUMANA
WI41975200Medicaid
WI067P 73-601Medicare PIN
006806261BOtherHUMANA
WI0254 68-086Medicare PIN