Healthcare Provider Details

I. General information

NPI: 1770540122
Provider Name (Legal Business Name): LAWRENCE D WEIDELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

IV. Provider business mailing address

12469 US HIGHWAY 98 W
MIRAMAR BEACH FL
32550-8305
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-4168
  • Fax: 458-201-8510
Mailing address:
  • Phone: 850-654-3376
  • Fax: 850-654-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA217838
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: