Individual
ERICH A WIDEMARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD, FNP-BC
Contact information
Practice address
14415 W MCDOWELL RD, GOODYEAR, GOODYEAR, AZ 85395-2521
(623) 512-4190
(623) 512-4194
Mailing address
14415 W MCDOWELL RD, SUITE D2, GOODYEAR, AZ 85395-2521
(623) 512-4190
(623) 512-4194
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
083736
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
630344
—
AZ
05
—
630344001
—
AZ
Enumeration date
09/20/2005
Last updated
11/19/2009
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