Provider Demographics
NPI:1992821052
Name:WEBER, PAMELA T (MPT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:T
Last Name:WEBER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14357 RAVEN ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3362
Mailing Address - Country:US
Mailing Address - Phone:312-371-8393
Mailing Address - Fax:
Practice Address - Street 1:7250 FRANCE AVE S
Practice Address - Street 2:SUITE 305
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4305
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:952-285-2830
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0107912251P0200X
MN9197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1992821052Medicaid