Healthcare Provider Details

I. General information

NPI: 1285873448
Provider Name (Legal Business Name): ANDREA R WEIGAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA R HEVERN PA-C

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 S LA CASSIA DR
BOISE ID
83705-2253
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-0086
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-466-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1161
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005914
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2785
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: