Basic Information
| Provider Information | |||||||||
| NPI: | 1164890547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WETHERHOLD | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 N BROAD ST RM 1A | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191404106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159269019 | ||||||||
| FaxNumber: | 6142933381 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2157285507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA057699 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0181073 | 05 | OH | MEDICAID |