Basic Information
| Provider Information | |||||||||
| NPI: | 1679583256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEIDEN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968631 | ||||||||
| FaxNumber: | 9077968455 | ||||||||
| Practice Location | |||||||||
| Address1: | 3260 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077968631 | ||||||||
| FaxNumber: | 9077968455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 4185 | AK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | MD4752 | 05 | AK | MEDICAID |