Provider Demographics
NPI:1922042464
Name:WEBER, COLETTE D (PA)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:D
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:MARIE
Other - Last Name:DREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4400 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9203
Practice Address - Country:US
Practice Address - Phone:208-442-2388
Practice Address - Fax:208-466-3403
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02922363A00000X
IDPA-873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS806975Medicare ID - Type Unspecified
MDQ28990Medicare UPIN