Provider Demographics
NPI:1174753362
Name:WEBER, MATT ALAN (DPT)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:ALAN
Last Name:WEBER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 N INWOOD ST APT 1103
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-7801
Mailing Address - Country:US
Mailing Address - Phone:316-207-2625
Mailing Address - Fax:
Practice Address - Street 1:621 W 21ST ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8498
Practice Address - Country:US
Practice Address - Phone:316-733-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist