Provider Demographics
NPI:1245235662
Name:WEISS, JANE E (PA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:WEISS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 BUTTS AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1412
Mailing Address - Country:US
Mailing Address - Phone:608-372-5951
Mailing Address - Fax:
Practice Address - Street 1:325 BUTTS AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1412
Practice Address - Country:US
Practice Address - Phone:608-372-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42951100Medicaid
WI0202Medicare PIN
WI42951100Medicaid