Basic Information
| Provider Information | |||||||||
| NPI: | 1831419332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIDERMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CARLTON | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 3645 E. OVERLAND RD. | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088887765 | ||||||||
| FaxNumber: | 2088887955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2663 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0330321 | 01 | ID | WA L&I | OTHER | 1831419332 | 05 | ID | MEDICAID | P00846336 | 01 | ID | RR MEDICARE | OTHER |