Provider Demographics
NPI:1932288875
Name:WIDENER, BRIAN KEITH (DC, RN, CRNA)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:WIDENER
Suffix:
Gender:M
Credentials:DC, RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 SHULER HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHILHOWIE
Mailing Address - State:VA
Mailing Address - Zip Code:24319-5647
Mailing Address - Country:US
Mailing Address - Phone:276-780-2960
Mailing Address - Fax:
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-1000
Practice Address - Fax:276-258-1405
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555564111N00000X
VA0024175795367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA227319OtherANTHEM BC/BS
VA227319OtherANTHEM BC/BS