Provider Demographics
NPI:1972992220
Name:WEATHERHOLTZ, ALYSHA A (PA)
Entity type:Individual
Prefix:
First Name:ALYSHA
Middle Name:A
Last Name:WEATHERHOLTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-6806
Mailing Address - Country:US
Mailing Address - Phone:405-282-6301
Mailing Address - Fax:405-282-6364
Practice Address - Street 1:2919 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-6806
Practice Address - Country:US
Practice Address - Phone:405-282-6301
Practice Address - Fax:405-282-6364
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant