Provider Demographics
NPI:1730673419
Name:WEBER, TYSEN L (MD)
Entity type:Individual
Prefix:DR
First Name:TYSEN
Middle Name:L
Last Name:WEBER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6352
Mailing Address - Country:US
Mailing Address - Phone:208-289-0425
Mailing Address - Fax:208-568-9850
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61156866208000000X
IDM-15702208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1730673419Medicaid
ID1730673419Medicaid