Provider Demographics
NPI:1053067181
Name:WIEDEMAN, ELEANOR RACHAEL (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:RACHAEL
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELLIE
Other - Middle Name:
Other - Last Name:WIEDEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:330 WELLINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9304
Mailing Address - Country:US
Mailing Address - Phone:513-594-4534
Mailing Address - Fax:
Practice Address - Street 1:330 WELLINGTON WAY
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9304
Practice Address - Country:US
Practice Address - Phone:513-594-4534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011030TMP22363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical