Provider Demographics
NPI:1073060034
Name:WIDENER, SCOTT ALDEN (FNP-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALDEN
Last Name:WIDENER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1387
Mailing Address - Country:US
Mailing Address - Phone:541-963-1412
Mailing Address - Fax:541-963-1488
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-1412
Practice Address - Fax:541-963-1488
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201704653NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner