Healthcare Provider Details

I. General information

NPI: 1962053579
Provider Name (Legal Business Name): BENJAMIN J WEYER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SCOTT ROLEN DR
JASPER IN
47546-2700
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-5656
  • Fax: 812-482-9758
Mailing address:
  • Phone: 812-996-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002802A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: