Provider Demographics
NPI:1700990223
Name:IVERSON-WIDDISON, MARCIA KAY (FNP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:KAY
Last Name:IVERSON-WIDDISON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 SHASTA WAY
Mailing Address - Street 2:SUITE #7
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4455
Mailing Address - Country:US
Mailing Address - Phone:541-882-2118
Mailing Address - Fax:
Practice Address - Street 1:2655 SHASTA WAY
Practice Address - Street 2:SUITE #7
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4455
Practice Address - Country:US
Practice Address - Phone:541-882-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily