Provider Demographics
NPI:1154564888
Name:WEIDLER, GRANT EVANS (LAC)
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:EVANS
Last Name:WEIDLER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:33300 EGYPT LN STE C700
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-2875
Mailing Address - Country:US
Mailing Address - Phone:281-744-2040
Mailing Address - Fax:281-617-4257
Practice Address - Street 1:33300 EGYPT LN STE C700
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2875
Practice Address - Country:US
Practice Address - Phone:281-744-2040
Practice Address - Fax:281-617-4257
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC01119OtherTEXAS MEDICAL BOARD/TEXAS BOARD OF ACUPUNCTURE EXAMINERS
TXAC01119OtherTEXAS MEDICAL BOARD/TEXAS BOARD OF ACUPUNCTURE EXAMINERS