MEDICARE: LAWRENCE D WEIDELL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA217838	OR

General Provider Information

NPI Number	:	1770540122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE D WEIDELL PA-C

Provider Business Mailing Address
First Line	:	12469 US HIGHWAY 98 W
Second Line	:
City	:	MIRAMAR BEACH
State	:	FL
Zip	:	32550-8305
Country	:	US
Telephone Number	:	850-654-3376
Fax Number	:	850-654-3320

Provider Business Practice Location Address
First Line	:	860 BELTLINE RD
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-1091
Country	:	US
Telephone Number	:	541-344-4168
Fax Number	:	458-201-8510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	10/03/2025

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