Provider Demographics
NPI:1841252459
Name:WEISNER, LARRY FELIX (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:FELIX
Last Name:WEISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:9536 HOSPITAL AVENUE
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-414-8490
Practice Address - Fax:757-414-8560
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400669208600000X
VA0101050970208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790156QMedicaid
VA1841252459Medicaid
NC2263058Medicare ID - Type Unspecified
VAVV4171BMedicare PIN
NCF79657Medicare UPIN
VAP01018762Medicare PIN