Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 3009646 | KY |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | COA.14647-NP | OH |
NPI | 1992146740 |
---|---|
Provider Name | Michael Jerome Weller |
First Address | Cincinnati, OH 45263-6256 |
Second Address | Edgewood, KY 41017-3403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2013 |
Last Update Date | 26/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0215521 | (05) | OH |