Provider Demographics
NPI:1912956806
Name:WIBERG, RALENE (MD)
Entity type:Individual
Prefix:DR
First Name:RALENE
Middle Name:
Last Name:WIBERG
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 1:211 16TH AVE N
Mailing Address - Street 2:PO BOX 9
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4058
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:211 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-461-7149
Practice Address - Fax:208-467-3391
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP464A363LX0001X
VA0101252362207Q00000X
IDM-12117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP464AOtherNP LICENSE