Provider Demographics
NPI:1295037844
Name:WEIDNER, PHILIP LOUIS II (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:LOUIS
Last Name:WEIDNER
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 N NORTHWOOD CENTER CT STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6190
Mailing Address - Country:US
Mailing Address - Phone:208-457-4211
Mailing Address - Fax:208-773-1473
Practice Address - Street 1:1233 N NORTHWOOD CENTER CT STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6190
Practice Address - Country:US
Practice Address - Phone:208-457-4211
Practice Address - Fax:208-773-1473
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2065363AS0400X, 363A00000X, 363AM0700X
WAPA60191252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical