MEDICARE: AUDREY WIEGMANN PA-C

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	085.006820	IL

General Provider Information

NPI Number	:	1962976803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY WIEGMANN PA-C

Provider Business Mailing Address
First Line	:	401 S CHERRY ST
Second Line	:
City	:	BREESE
State	:	IL
Zip	:	62230-2013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 PARKLAND BLVD STE 225
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-4103
Country	:	US
Telephone Number	:	216-273-9800
Fax Number	:

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

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	09/13/2024

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