Provider Demographics
NPI:1104469055
Name:WIEDEMANN, AVA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:MARIE
Last Name:WIEDEMANN
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 1:2131 E GRETTA PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3436
Mailing Address - Country:US
Mailing Address - Phone:602-793-6456
Mailing Address - Fax:
Practice Address - Street 1:9665 CHESAPEAKE DR STE 350
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1352
Practice Address - Country:US
Practice Address - Phone:877-260-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant