Provider Demographics
NPI:1235110628
Name:WIDENOJA, PATRICIA DIANE (BSN, MN, FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:WIDENOJA
Suffix:
Gender:F
Credentials:BSN, MN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85955 RAVEN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:OR
Mailing Address - Zip Code:97638-9627
Mailing Address - Country:US
Mailing Address - Phone:541-576-3070
Mailing Address - Fax:541-576-3070
Practice Address - Street 1:85955 RAVEN RIDGE LN
Practice Address - Street 2:
Practice Address - City:SILVER LAKE
Practice Address - State:OR
Practice Address - Zip Code:97638-9627
Practice Address - Country:US
Practice Address - Phone:541-576-3070
Practice Address - Fax:541-576-3070
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR078041667N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORANP0170OtherWORKERS COMPENSATION
OR051750Medicaid
ORMWOO73609OtherDEA
ORS15895Medicare UPIN