Provider Demographics
NPI:1972139418
Name:WIEDENHOFT, LARRY MICHAEL (EMT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:MICHAEL
Last Name:WIEDENHOFT
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:MANZANITA
Mailing Address - State:OR
Mailing Address - Zip Code:97130-0810
Mailing Address - Country:US
Mailing Address - Phone:503-704-1006
Mailing Address - Fax:
Practice Address - Street 1:465 MANZANITA AVE
Practice Address - Street 2:
Practice Address - City:MANZANITA
Practice Address - State:OR
Practice Address - Zip Code:97130-0810
Practice Address - Country:US
Practice Address - Phone:503-704-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR143317207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services