Healthcare Provider Details

I. General information

NPI: 1053727032
Provider Name (Legal Business Name): THOMAS WEIDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BALL STATE UNIV 2000 W. UNIVERSITY AVE.
MUNCIE IN
47306-0270
US

IV. Provider business mailing address

BALL STATE UNIV 2000 W. UNIVERSITY AVE.
MUNCIE IN
47306-0270
US

V. Phone/Fax

Practice location:
  • Phone: 765-285-5039
  • Fax: 765-285-5610
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000200A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: