Healthcare Provider Details

I. General information

NPI: 1013912104
Provider Name (Legal Business Name): COREY WEIDMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JACKSON RIVER ORTHOPEDICS 1 ARH LANE, STE 102
LOW MOOR VA
24457
US

IV. Provider business mailing address

PO BOX 457 5 E ALVON ROAD, SUITE 7
WHITE SULPHUR SPRINGS WV
24986-2373
US

V. Phone/Fax

Practice location:
  • Phone: 540-862-6777
  • Fax: 540-863-9167
Mailing address:
  • Phone: 304-536-5030
  • Fax: 304-536-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110840643
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: