Provider Demographics
NPI:1053685198
Name:WEBER, ANDREA C (LAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:C
Last Name:WEBER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7439
Mailing Address - Country:US
Mailing Address - Phone:503-734-7508
Mailing Address - Fax:503-664-4164
Practice Address - Street 1:709 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-734-7508
Practice Address - Fax:503-664-4164
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156402171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
500698682OtherDMAP