Provider Demographics
NPI:1821617416
Name:WEISS, ALI SUE HAINES (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:SUE HAINES
Last Name:WEISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:SUE
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 BISHOP RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3939
Mailing Address - Country:US
Mailing Address - Phone:307-332-4420
Mailing Address - Fax:
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-332-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17285A207VX0000X
NE17285A207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine