Provider Demographics
NPI:1285687004
Name:WEBER, LUANN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:ELIZABETH
Last Name:WEBER
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 1:240 WILLOW ST.
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-0240
Mailing Address - Country:US
Mailing Address - Phone:507-247-5921
Mailing Address - Fax:507-247-5184
Practice Address - Street 1:240 WILLOW ST.
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-0240
Practice Address - Country:US
Practice Address - Phone:507-247-5921
Practice Address - Fax:507-247-5184
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9146363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN363716600Medicaid
MNS06702Medicare UPIN
MN363716600Medicaid