1326192212 NPI number — TAMARA M WEBER PT

Table of content: TAMARA M WEBER PT (NPI 1326192212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326192212 NPI number — TAMARA M WEBER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBER
Provider First Name:
TAMARA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TUTTLE
Provider Other First Name:
TAMARA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326192212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 SW INDUSTRIAL WAY
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-1093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-585-2529
Provider Business Mailing Address Fax Number:
541-585-2536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-416-7476
Provider Business Practice Location Address Fax Number:
541-416-7478
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2935 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022551 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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