=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053838292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA WEIR PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3211 E MOORES PIKE
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47401-7129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-509-4871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 AVOCA EUREKA RD
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-8405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 06003327A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------