Provider Demographics
NPI:1003888033
Name:WEESE, MAXWELL RICHARD (PA)
Entity Type:Individual
Prefix:MR
First Name:MAXWELL
Middle Name:RICHARD
Last Name:WEESE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NASHUA CT
Mailing Address - Street 2:SUITE H
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3133
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:410-933-4835
Practice Address - Street 1:901 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3416
Practice Address - Country:US
Practice Address - Phone:410-682-5500
Practice Address - Fax:410-682-3803
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001754363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD327Medicare ID - Type Unspecified
MDP64106Medicare UPIN