Provider Demographics
NPI:1164580536
Name:WEBSTER, BRIAN R (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:R
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-8428
Mailing Address - Country:US
Mailing Address - Phone:970-521-8858
Mailing Address - Fax:
Practice Address - Street 1:530 TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33953
Practice Address - Country:US
Practice Address - Phone:941-391-5296
Practice Address - Fax:941-391-5297
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant