Healthcare Provider Details

I. General information

NPI: 1235110628
Provider Name (Legal Business Name): PATRICIA DIANE WIDENOJA BSN, MN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 03/07/2023
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85955 RAVEN RIDGE LN
SILVER LAKE OR
97638-9627
US

IV. Provider business mailing address

85955 RAVEN RIDGE LN
SILVER LAKE OR
97638-9627
US

V. Phone/Fax

Practice location:
  • Phone: 541-576-3070
  • Fax: 541-576-3070
Mailing address:
  • Phone: 541-576-3070
  • Fax: 541-576-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number078041667N1
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierANP0170
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerWORKERS COMPENSATION
# 2
Identifier051750
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: