Provider Demographics
NPI:1770540122
Name:WEIDELL, LAWRENCE D (PA-C)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:D
Last Name:WEIDELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12469 US HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8305
Mailing Address - Country:US
Mailing Address - Phone:850-654-3376
Mailing Address - Fax:850-654-3320
Practice Address - Street 1:2924 SISKIYOU BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6462
Practice Address - Country:US
Practice Address - Phone:541-200-2777
Practice Address - Fax:541-214-2575
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10072363A00000X
ORPA217838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P49420Medicare UPIN