Provider Demographics
NPI:1750071767
Name:WEIGLE, PAUL (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WEIGLE
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 1:96 S 100 W
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:UT
Mailing Address - Zip Code:84340-9764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 S 100 W
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:UT
Practice Address - Zip Code:84340-9764
Practice Address - Country:US
Practice Address - Phone:435-740-9314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT14184833-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program