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Individual
MRS. SHANNON M. WIDDERICK
Active
Individual
MRS. SHANNON M. WIDDERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
001992
CT
363A00000X
Physician Assistant
2360
MA
363A00000X
Physician Assistant
Primary
PA2360
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003019924
—
CT
Enumeration date
12/03/2007
Last updated
01/02/2013
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