Provider Demographics
NPI:1427222355
Name:WEERSING, NICOLE JEANETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JEANETTE
Last Name:WEERSING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JEANETTE
Other - Last Name:MECHALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-0900
Practice Address - Fax:410-601-0901
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03106363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS589Medicare PIN
MDS574Medicare PIN
MD128201YSHMedicare PIN
MD128201Y8SMedicare PIN