Provider Demographics
NPI:1396715371
Name:WESTON, TROY D (PA)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:D
Last Name:WESTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E HOWARD ST
Mailing Address - Street 2:TETON VALLEY HEALTH CARE
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6302
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:120 E HOWARD ST
Practice Address - Street 2:TETON VALLEY HEALTH CARE
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-6302
Practice Address - Fax:208-354-3158
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA212363AM0700X
IDPA 212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806633300Medicaid
IDPASROOtherBLUE CROSS
ID806633300Medicaid
S87886Medicare UPIN