Provider Demographics
NPI:1861486961
Name:WEATHERWAX, ANGELA M (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:WEATHERWAX
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 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 2050
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3912
Practice Address - Country:US
Practice Address - Phone:614-566-2450
Practice Address - Fax:614-566-1895
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002174363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068168Medicaid
OH0068168Medicaid