Provider Demographics
NPI:1194774554
Name:WEBER, NANCY A (PA-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:SUITE C-240
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-266-0878
Mailing Address - Fax:801-266-2074
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4968
Practice Address - Country:US
Practice Address - Phone:801-296-6665
Practice Address - Fax:801-296-6667
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106900-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTB0555Medicaid
UTS75966Medicare UPIN
UTB0555Medicaid