Provider Demographics
NPI:1407898257
Name:WETTERHAHN, REGINA M (PA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:WETTERHAHN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:M
Other - Last Name:BUCKINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1575 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9371
Mailing Address - Country:US
Mailing Address - Phone:315-786-7300
Mailing Address - Fax:315-786-7310
Practice Address - Street 1:1575 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9371
Practice Address - Country:US
Practice Address - Phone:315-786-7300
Practice Address - Fax:315-786-7310
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354316Medicaid
NY00354316Medicaid