Provider Demographics
NPI:1851322002
Name:WINDERWEEDLE, JEREMY L (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
Last Name:WINDERWEEDLE
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 1:12550 HESPERIA RD
Mailing Address - Street 2:STE 100
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5873
Mailing Address - Country:US
Mailing Address - Phone:760-241-6666
Mailing Address - Fax:760-241-7575
Practice Address - Street 1:12550 HESPERIA RD
Practice Address - Street 2:STE 100
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5873
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-241-7575
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16640OtherLICENSE
CAQ13164Medicare UPIN