Provider Demographics
NPI:1114978368
Name:WIDSTROM, AMBER J (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:J
Last Name:WIDSTROM
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:11033 CROWN POINT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1507
Mailing Address - Country:US
Mailing Address - Phone:402-496-6559
Mailing Address - Fax:402-933-6501
Practice Address - Street 1:988095 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8095
Practice Address - Country:US
Practice Address - Phone:402-559-9800
Practice Address - Fax:402-559-9840
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-11-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE1098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ01566Medicare UPIN
NE277193Medicare ID - Type Unspecified