Provider Demographics
NPI:1942552641
Name:WEINBERG, LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WEINBERG
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 1:1352 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4185
Mailing Address - Country:US
Mailing Address - Phone:810-230-0001
Mailing Address - Fax:810-230-0014
Practice Address - Street 1:1352 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4185
Practice Address - Country:US
Practice Address - Phone:810-230-0001
Practice Address - Fax:810-230-0014
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003418OtherSTATE LICENSE