Basic Information
| Provider Information | |||||||||
| NPI: | 1245636836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEINER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ERIN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 HEALTH CARE DRIVE | ||||||||
| Address2: | |||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264160900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 HEALTH CARE DR | ||||||||
| Address2: | |||||||||
| City: | PHILIPPI | ||||||||
| State: | WV | ||||||||
| PostalCode: | 264160900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044572800 | ||||||||
| FaxNumber: | 3044574011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2014 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 01852 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 01852 | 01 | WV | WV LICENSE # | OTHER |