Provider Demographics
NPI:1578638029
Name:WESTON, THOMAS D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:D
Last Name:WESTON
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 1:4 DEERWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1296
Mailing Address - Country:US
Mailing Address - Phone:218-631-1100
Mailing Address - Fax:
Practice Address - Street 1:4 DEERWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1296
Practice Address - Country:US
Practice Address - Phone:218-631-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10417363A00000X
NDPAC0161363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18709Medicaid
ND18709Medicaid
S14334Medicare UPIN