KIM KEITH WIESE Physician Assistant License verification

Business Entity

ACTIVE

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****16

License Status

ACTIVE

Business

First Name

KIM

Middle

KEITH

Last Name

WIESE

Business Name

KIM KEITH WIESE

Original Issue Date

12/09/2019

Effective Date

12/05/2025

Expiration Date

03/01/2028

City

PEORIA

State

Zip

61614

County

PEORIA

Delegated Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

12/05/2025