Healthcare Provider Details

I. General information

NPI: 1932516002
Provider Name (Legal Business Name): TINA LOUISE WIDA RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 UNION STATION PLAZA
BETHLEHEM PA
18015
US

IV. Provider business mailing address

240 UNION STATION PLAZA
BETHLEHEM PA
18015
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-2786
  • Fax: 484-893-7096
Mailing address:
  • Phone: 484-526-2786
  • Fax: 484-893-7096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-504154-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN505154L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: