Provider Demographics
NPI:1851573018
Name:ALLAN N. WEISSMAN, M.D.
Entity Type:Organization
Organization Name:ALLAN N. WEISSMAN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-876-9158
Mailing Address - Street 1:1950 POTTERY AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2590
Mailing Address - Country:US
Mailing Address - Phone:360-846-9158
Mailing Address - Fax:360-876-9220
Practice Address - Street 1:1950 POTTERY AVE STE 20
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2590
Practice Address - Country:US
Practice Address - Phone:360-846-9158
Practice Address - Fax:360-876-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1038579Medicaid
WYG000200544Medicare PIN