Provider Demographics
NPI:1962438812
Name:WEBER, DAN LOREN (PA-C)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:LOREN
Last Name:WEBER
Suffix:
Gender:M
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 1:256 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1638
Mailing Address - Country:US
Mailing Address - Phone:208-656-9646
Mailing Address - Fax:208-656-9646
Practice Address - Street 1:256 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1638
Practice Address - Country:US
Practice Address - Phone:208-656-9646
Practice Address - Fax:208-656-9646
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPATX3OtherBLUE CROSS OF IDAHO
S51308Medicare UPIN
1667140Medicare ID - Type Unspecified
ID805102800Medicaid
ID000010148920OtherREGENCE BLUE SHIELD OF ID