Provider Demographics
NPI:1902990963
Name:WEBER, MICHAEL THOMAS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:WEBER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LATHROP ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-452-4446
Mailing Address - Fax:907-451-9480
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 209
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-452-4446
Practice Address - Fax:907-451-9480
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
152822OtherMC GROUP
AKMD45451Medicaid
152823Medicare ID - Type UnspecifiedINDIV
R73968Medicare UPIN