Basic Information
Provider Information | |||||||||
NPI: | 1679877187 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WETZEL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 HOSPITAL DR | ||||||||
Address2: | SUITE 306 | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178379350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705224110 | ||||||||
FaxNumber: | 5707683911 | ||||||||
Practice Location | |||||||||
Address1: | 7905 WESTBRANCH HIGHWAY | ||||||||
Address2: | SUITE 1100 | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178376808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705245050 | ||||||||
FaxNumber: | 5705245250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2010 | ||||||||
LastUpdateDate: | 11/29/2016 | ||||||||
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 | 363AM0700X | MA054769 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1031712290002 | 05 | PA |   | MEDICAID |