Provider Demographics
NPI:1457745101
Name:PAT WIDENOJA FNP
Entity Type:Organization
Organization Name:PAT WIDENOJA FNP
Other - Org Name:NORTH LAKE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIDENOJA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, DNP
Authorized Official - Phone:541-576-2343
Mailing Address - Street 1:POB377
Mailing Address - Street 2:87520 BAY RD
Mailing Address - City:CHRISTMAS VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97641
Mailing Address - Country:US
Mailing Address - Phone:541-576-2343
Mailing Address - Fax:541-576-2869
Practice Address - Street 1:87520 BAY RD
Practice Address - Street 2:POB 377
Practice Address - City:CHRISTMAS VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97641-0377
Practice Address - Country:US
Practice Address - Phone:541-576-2343
Practice Address - Fax:541-576-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR078041667261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center