Basic Information
| Provider Information | |||||||||
| NPI: | 1558802355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIRICH | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALLORY | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915150 | ||||||||
| FaxNumber: | 4194796173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SEAGATE | ||||||||
| Address2: | #800 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675851983 | ||||||||
| FaxNumber: | 4198247359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2017 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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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 | 50.005051RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.