Provider Demographics
NPI:1295277077
Name:WEBER, MALLORY BETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:BETH
Last Name:WEBER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MALLORY
Other - Middle Name:BETH
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 OVALTINE CT
Mailing Address - Street 2:APT 309
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5606
Mailing Address - Country:US
Mailing Address - Phone:217-556-7274
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 809
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5904
Practice Address - Fax:312-942-3192
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant