Individual
MR. LARRY MICHAEL WIEDENHOFT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
EMT
Contact information
Practice address
465 MANZANITA AVE, MANZANITA, OR 97130-0810
(503) 704-1006
Mailing address
PO BOX 810, MANZANITA, OR 97130-0810
(503) 704-1006
Taxonomy
Speciality
Code
Description
License number
State
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
143317
OR
Other
Enumeration date
03/17/2020
Last updated
03/17/2020
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