Provider Demographics
NPI:1144579780
Name:WEEDEN, RENEE (PA-C)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:WEEDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 WINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-7010
Mailing Address - Country:US
Mailing Address - Phone:845-649-5243
Mailing Address - Fax:
Practice Address - Street 1:601 S NEW YORK AVE STE A-101
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4358
Practice Address - Country:US
Practice Address - Phone:407-777-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106565363A00000X
FLPA9106565207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology