Provider Demographics
NPI:1407178577
Name:WIDNER, PAUL EDWARD (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDWARD
Last Name:WIDNER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-9310
Mailing Address - Country:US
Mailing Address - Phone:574-773-4127
Mailing Address - Fax:574-773-4099
Practice Address - Street 1:2101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-9310
Practice Address - Country:US
Practice Address - Phone:574-773-4127
Practice Address - Fax:574-773-4099
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000256A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer