Provider Demographics
NPI:1891446605
Name:WEA MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:WEA MEDICAL GROUP, PLLC
Other - Org Name:WELLNESS AND EQUITY ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRISON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOBDELL
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:770-833-7391
Mailing Address - Street 1:1709 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1709 DRAKE AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3526
Practice Address - Country:US
Practice Address - Phone:770-833-7391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4261893Medicaid