Provider Demographics
NPI:1689180770
Name:WIDHALM, PETER (PTA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WIDHALM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 MARTHA ST APT 11E
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-3168
Mailing Address - Country:US
Mailing Address - Phone:631-871-2593
Mailing Address - Fax:
Practice Address - Street 1:2900 F ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1533
Practice Address - Country:US
Practice Address - Phone:402-731-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1184225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant