Provider Demographics
NPI:1669063582
Name:WIDENER, NICKOLAS (CRNA)
Entity type:Individual
Prefix:MR
First Name:NICKOLAS
Middle Name:
Last Name:WIDENER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6632 SPRINGFIELD VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8986
Mailing Address - Country:US
Mailing Address - Phone:336-406-4343
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-406-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6537367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered