Healthcare Provider Details

I. General information

NPI: 1689182529
Provider Name (Legal Business Name): WESLEY D WEIDLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 161ST AVE NE STE 202
REDMOND WA
98052-3858
US

IV. Provider business mailing address

2912 SPRINGBORO W
MORAINE OH
45439-1674
US

V. Phone/Fax

Practice location:
  • Phone: 425-979-4339
  • Fax:
Mailing address:
  • Phone: 937-855-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.005416RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61039111
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: