Provider Demographics
NPI:1275077281
Name:WEITENDORF, ANITA M (PA-C)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:WEITENDORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:M
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:617-726-3884
Mailing Address - Fax:
Practice Address - Street 1:7 MARSH BROOK DR
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878
Practice Address - Country:US
Practice Address - Phone:603-742-2007
Practice Address - Fax:603-749-4605
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3106649Medicaid