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General NPI Number Information
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NPI Number | 1861600017
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Entity Type | Individual
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Provider Name | TIMOTHY L. WEIDE P.A.
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Gender | Male
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Dates
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Enumeration Date | 05/20/2007
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Last Update Date | 02/01/2008
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Provider Practice Location Address
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Address Line | 1121 N COLLEGE PARK ST SUITE # 400
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City | DERBY
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State | KS
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Zip | 67037-3665
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Country | US
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Telephone | 316-788-3376
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Fax | 316-788-3378
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Provider Business Mailing Address
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Address Line | 22120 SW WILLIAMS RD
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City | DOUGLASS
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State | KS
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Zip | 67039-8539
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1500761
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License Number State | KS
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