Provider Demographics
NPI:1538367909
Name:WEBER, MARY C (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WEBER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S TOPAZ WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4474
Mailing Address - Country:US
Mailing Address - Phone:208-605-7070
Mailing Address - Fax:
Practice Address - Street 1:7416 212TH ST SW
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7602
Practice Address - Country:US
Practice Address - Phone:425-245-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60218656363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0286559OtherLABOR AND INDUSTRIES- WASHINGTON STATE
MT1538367909Medicaid
MT0000371561OtherBLUE CROSS BLUE SHIELD
MT0000371561OtherBLUE CROSS BLUE SHIELD
MT1538367909Medicaid