Provider Demographics
NPI:1457499717
Name:WEITZMAN, AUDREY G (PA)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:G
Last Name:WEITZMAN
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 1:20528 BOLAND FARM RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4021
Mailing Address - Country:US
Mailing Address - Phone:301-972-0400
Mailing Address - Fax:301-916-1453
Practice Address - Street 1:20528 BOLAND FARM RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4021
Practice Address - Country:US
Practice Address - Phone:301-972-0400
Practice Address - Fax:301-916-1453
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPA47713OtherCDS
MDPA47713OtherCDS