Provider Demographics
NPI:1265628606
Name:WEIDNER, BETH ANN (APRN)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52775 AVENIDA RAMIREZ
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-5300
Mailing Address - Country:US
Mailing Address - Phone:512-689-8088
Mailing Address - Fax:
Practice Address - Street 1:5920 MCINTYRE ST
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-7445
Practice Address - Country:US
Practice Address - Phone:303-949-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95006166363LF0000X
TX514070363LF0000X
COAPN.0990379-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94535272Medicaid