Provider Demographics
NPI:1336562883
Name:WIDMER, ELIZABETH SUZANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUZANNE
Last Name:WIDMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12469 TIMBERLAND BLVD STE 501
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5216
Mailing Address - Country:US
Mailing Address - Phone:817-431-6555
Mailing Address - Fax:817-431-7979
Practice Address - Street 1:12469 TIMBERLAND BLVD STE 501
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5216
Practice Address - Country:US
Practice Address - Phone:817-431-6555
Practice Address - Fax:817-431-7979
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08702363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical