Basic Information
| Provider Information | |||||||||
| NPI: | 1265628606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIDNER | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 52775 AVENIDA RAMIREZ | ||||||||
| Address2: | |||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922535300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126898088 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039491250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP95006166 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 514070 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | APN.0990379-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 94535272 | 05 | CO | MEDICAID |