Basic Information
| Provider Information | |||||||||
| NPI: | 1437566874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KLOSTERMAN | ||||||||
| OtherFirstName: | ELYSE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9372779035 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9372779035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.004107 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0110577 | 05 | OH | MEDICAID |