Provider Demographics
NPI:1962873810
Name:WESSEL, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:WESSEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 W RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4708
Mailing Address - Country:US
Mailing Address - Phone:937-307-7484
Mailing Address - Fax:
Practice Address - Street 1:7073 CLYO RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4816
Practice Address - Country:US
Practice Address - Phone:937-307-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant