Provider Demographics
NPI:1891950853
Name:WEIDNER, PHILLIP T (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:T
Last Name:WEIDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 SPORTSMAN DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-4193
Mailing Address - Country:US
Mailing Address - Phone:303-868-8247
Mailing Address - Fax:
Practice Address - Street 1:4921 SPORTSMAN DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-4193
Practice Address - Country:US
Practice Address - Phone:303-868-8247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO158703207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine