Provider Demographics
NPI:1104929553
Name:WEBER, WALLACE NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:NICHOLAS
Last Name:WEBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19748 MICHAELIS ROAD
Mailing Address - Street 2:
Mailing Address - City:DORRANCE
Mailing Address - State:KS
Mailing Address - Zip Code:67634
Mailing Address - Country:US
Mailing Address - Phone:785-666-4341
Mailing Address - Fax:785-666-4341
Practice Address - Street 1:19748 MICHAELIS ROAD
Practice Address - Street 2:
Practice Address - City:DORRANCE
Practice Address - State:KS
Practice Address - Zip Code:67634
Practice Address - Country:US
Practice Address - Phone:785-666-4341
Practice Address - Fax:785-666-4341
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0414492207N00000X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B68642Medicare UPIN