1770022535 NPI number — CAMILLE FAYE WEAS MA

Table of content: CAMILLE FAYE WEAS MA (NPI 1770022535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770022535 NPI number — CAMILLE FAYE WEAS MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAS
Provider First Name:
CAMILLE
Provider Middle Name:
FAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770022535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3810 W 31ST ST APT 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-5326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-790-5767
Provider Business Mailing Address Fax Number:
763-205-3702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8085 WAYZATA BLVD STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-1457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-790-5767
Provider Business Practice Location Address Fax Number:
763-205-3702
Provider Enumeration Date:
02/13/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1817 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)