Healthcare Provider Details

I. General information

NPI: 1659134682
Provider Name (Legal Business Name): NICHOLAS ALEXANDER WIDGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 JOHN DEERE RD
MOLINE IL
61265-9951
US

IV. Provider business mailing address

2323 8TH ST
SILVIS IL
61282-2804
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-5433
  • Fax:
Mailing address:
  • Phone: 563-650-4371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: