Provider Demographics
NPI:1013094820
Name:WEISS, ANN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:M
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-344-7799
Practice Address - Fax:208-344-7152
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5120620207P00000X
IDM-10998207P00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1013094820Medicaid
WI029050146Medicare PIN
WIP00758094Medicare PIN