Basic Information
Provider Information | |||||||||
NPI: | 1285873448 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEIGAND | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEVERN | ||||||||
OtherFirstName: | ANDREA | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 40732 VAN DYKE AVE | ||||||||
Address2: |   | ||||||||
City: | STERLING HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 483133741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5869771510 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 40732 VAN DYKE AVE | ||||||||
Address2: |   | ||||||||
City: | STERLING HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 483133741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5869771510 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2009 | ||||||||
LastUpdateDate: | 01/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1161 | NV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 5601005914 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 5601005914 | 01 | MI | STATE OF MICHIGAN | OTHER | 1161 | 01 | NV | NV PA LICENSE # | OTHER |