Provider Demographics
NPI:1952064891
Name:WEISENBERGER, RYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RYNE
Middle Name:
Last Name:WEISENBERGER
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 1:702 STARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9471
Mailing Address - Country:US
Mailing Address - Phone:810-623-6544
Mailing Address - Fax:
Practice Address - Street 1:4001 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3038
Practice Address - Country:US
Practice Address - Phone:313-993-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant