Provider Demographics
NPI:1851090237
Name:WIEDERHOLD, BRIAN ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ADAM
Last Name:WIEDERHOLD
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 1:9910 SANDALFOOT BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-6692
Mailing Address - Country:US
Mailing Address - Phone:561-883-3030
Mailing Address - Fax:561-852-7611
Practice Address - Street 1:9910 SANDALFOOT BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-6692
Practice Address - Country:US
Practice Address - Phone:561-883-3030
Practice Address - Fax:561-852-7611
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant