Basic Information
| Provider Information | |||||||||
| NPI: | 1194980680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIGHT | ||||||||
| FirstName: | JED | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593551 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593570 | ||||||||
| FaxNumber: | 9074593526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 7183 | AK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | FW2751659 | 01 | AK | DEA | OTHER | 1574695 | 05 | AK | MEDICAID |