Provider Demographics
NPI:1528582103
Name:WEISS, AUTUMN RAIN (PA)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:RAIN
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 HARDING PL
Practice Address - Street 2:STE 4400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant