Provider Demographics
NPI:1790704591
Name:WEBER, LARRY M (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:WEBER
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 1:2747 NE CONNERS AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8738
Mailing Address - Country:US
Mailing Address - Phone:541-382-5712
Mailing Address - Fax:541-382-2605
Practice Address - Street 1:2747 NE CONNERS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8738
Practice Address - Country:US
Practice Address - Phone:541-382-5712
Practice Address - Fax:541-382-2605
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR103768Medicare ID - Type Unspecified
ORS79677Medicare UPIN