Provider Demographics
NPI:1720221211
Name:WIDMER, LYLITH SKYE (MD)
Entity Type:Individual
Prefix:DR
First Name:LYLITH
Middle Name:SKYE
Last Name:WIDMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:LYN
Other - Last Name:WIDMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1782
Mailing Address - Street 2:
Mailing Address - City:HAINES
Mailing Address - State:AK
Mailing Address - Zip Code:99827-1782
Mailing Address - Country:US
Mailing Address - Phone:907-766-6335
Mailing Address - Fax:
Practice Address - Street 1:131 1ST AVE
Practice Address - Street 2:
Practice Address - City:HAINES
Practice Address - State:AK
Practice Address - Zip Code:99827
Practice Address - Country:US
Practice Address - Phone:907-766-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK7648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1571200Medicaid
AK8EN071Medicare PIN
AK1571200Medicaid
AK8EN069Medicare PIN