Provider Demographics
NPI:1639134653
Name:WIDDEKIND, DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WIDDEKIND
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:30 13TH ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-5222
Practice Address - Country:US
Practice Address - Phone:406-265-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN10583367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT19971OtherBLUE CROSS OF MT
MT0435200Medicaid
MT430052901Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MT0435200Medicaid