Provider Demographics
NPI:1376297846
Name:WIDDICOMBE, ISAAC
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:WIDDICOMBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6402 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2338
Mailing Address - Country:US
Mailing Address - Phone:971-506-2209
Mailing Address - Fax:
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183589367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered