Provider Demographics
NPI:1922625383
Name:WEILERT, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WEILERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 HARRY L DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1423
Mailing Address - Country:US
Mailing Address - Phone:607-777-9475
Mailing Address - Fax:339-212-8040
Practice Address - Street 1:256 HARRY L DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1423
Practice Address - Country:US
Practice Address - Phone:607-777-9475
Practice Address - Fax:339-212-8040
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350195363LF0000X
NY750339163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse