MEDICARE: MR. TIMOTHY L. WEIDE P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1500761	KS

General Provider Information

NPI Number	:	1861600017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY L. WEIDE P.A.

Provider Business Mailing Address
First Line	:	22120 SW WILLIAMS RD
Second Line	:
City	:	DOUGLASS
State	:	KS
Zip	:	67039-8539
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 N COLLEGE PARK ST
Second Line	:	SUITE # 400
City	:	DERBY
State	:	KS
Zip	:	67037-3665
Country	:	US
Telephone Number	:	316-788-3376
Fax Number	:	316-788-3378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	02/01/2008

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Directions to “ MR. TIMOTHY L. WEIDE P.A.” Practice Location

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