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Individual

DEREK WIDENER

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
PTA

Contact information

Practice address
1221 N DUTTON AVE, SANTA ROSA, CA 95401-4607
(707) 543-8360
Mailing address
1221 N DUTTON AVE, SANTA ROSA, CA 95401-4607

Taxonomy

Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
6568
CA

Other

Enumeration date
12/30/2011
Last updated
12/30/2011
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