Healthcare Provider Details

I. General information

NPI: 1477396018
Provider Name (Legal Business Name): WEBER PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 VINEYARD AVE
LEWISTON ID
83501-6352
US

IV. Provider business mailing address

901 22ND AVE
CLARKSTON WA
99403-3147
US

V. Phone/Fax

Practice location:
  • Phone: 971-209-8219
  • Fax:
Mailing address:
  • Phone: 971-209-8219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TYSEN WEBER
Title or Position: OWNER
Credential: MD
Phone: 971-209-8219