Provider Demographics
NPI:1245428929
Name:WIDMAN, MARY ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:WIDMAN
Suffix:
Gender:F
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 1:1713 S KOFA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-6477
Mailing Address - Country:US
Mailing Address - Phone:928-669-9700
Mailing Address - Fax:928-669-9104
Practice Address - Street 1:1713 S KOFA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6477
Practice Address - Country:US
Practice Address - Phone:928-669-9700
Practice Address - Fax:928-669-9104
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00458072OtherRAILROAD MEDICARE
AZCD2092Medicare PIN
AZP00458072OtherRAILROAD MEDICARE
AZ118880Medicare PIN