Provider Demographics
NPI:1528596343
Name:WEIMER, JONATHAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:WEIMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:843-552-0400
Mailing Address - Fax:843-552-1618
Practice Address - Street 1:5325 APPIAN WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7234
Practice Address - Country:US
Practice Address - Phone:843-552-0400
Practice Address - Fax:843-552-1618
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2998PAMedicaid