Provider Demographics
NPI:1326576836
Name:WEBER, COLLEEN (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26851 TANIC DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-4614
Mailing Address - Country:US
Mailing Address - Phone:631-672-0924
Mailing Address - Fax:
Practice Address - Street 1:26851 TANIC DR STE 102
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-4614
Practice Address - Country:US
Practice Address - Phone:813-701-5804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FL9117207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer