Provider Demographics
NPI:1346455995
Name:WIDEMAN, PALMA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:PALMA
Middle Name:ANNE
Last Name:WIDEMAN
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:PO BOX 1379
Mailing Address - Street 2:
Mailing Address - City:MEADOW VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95722-1379
Mailing Address - Country:US
Mailing Address - Phone:530-878-6361
Mailing Address - Fax:
Practice Address - Street 1:17080 LOGANBERRY COURT
Practice Address - Street 2:
Practice Address - City:MEADOW VISTA
Practice Address - State:CA
Practice Address - Zip Code:95722-1379
Practice Address - Country:US
Practice Address - Phone:530-878-6361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPWG47944Medicare ID - Type Unspecified
CAA50871Medicare UPIN