Provider Demographics
NPI:1972211787
Name:WIDENER, ANDRU ALAN
Entity Type:Individual
Prefix:
First Name:ANDRU
Middle Name:ALAN
Last Name:WIDENER
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 1:1182 GIBBONS RD S
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-6337
Mailing Address - Country:US
Mailing Address - Phone:916-251-6351
Mailing Address - Fax:
Practice Address - Street 1:1182 GIBBONS RD S
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:TX
Practice Address - Zip Code:76226-6337
Practice Address - Country:US
Practice Address - Phone:916-251-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant