Provider Demographics
NPI:1992714638
Name:WEBER, PAMELA L (PT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:WEBER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:L
Other - Last Name:JONSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:10342 DYNO DR
Practice Address - Street 2:STE 2
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6150
Practice Address - Country:US
Practice Address - Phone:715-699-1371
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3564-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400284168OtherMEDICARE PTAN
MN345C3WEOtherBCBS OF MN
WI000286021Medicare ID - Type Unspecified
WIP00330650OtherRAILROAD MEDICARE
WI64-05757OtherMEDICA
WI001386020OtherMEDICARE
WI356402400005OtherBCBS OF WI
WI64-07679OtherMEDICA
WI97655OtherSECURITY HEALTH PLAN
WIP00468116OtherRAILROAD MEDICARE
WI40378000Medicaid
WI64-07678OtherMEDICA