Provider Demographics
NPI:1013912104
Name:WEIDMAN, COREY (PA-C)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WEIDMAN
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:PO BOX 457
Mailing Address - Street 2:5 E ALVON ROAD, SUITE 7
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2373
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5051
Practice Address - Street 1:JACKSON RIVER ORTHOPEDICS
Practice Address - Street 2:1 ARH LANE, STE 102
Practice Address - City:LOW MOOR
Practice Address - State:VA
Practice Address - Zip Code:24457
Practice Address - Country:US
Practice Address - Phone:540-862-6777
Practice Address - Fax:540-863-9167
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV54183971800OtherWV WORKERS COMPENSATION
VA541839718045OtherBS MOUNTAIN STATE
541839718OtherC&O
WV001717977OtherBSMT
200026OtherLUNG
VA258083OtherANTHEM
200026OtherLUNG
1200890004Medicare ID - Type UnspecifiedADMINSTAR FEDERAL
541839718OtherC&O
S31444Medicare UPIN
VA970000182Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH/VAMC`