Healthcare Provider Details

I. General information

NPI: 1306512371
Provider Name (Legal Business Name): LEVI SAMUEL WIDENER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 MEDICAL PARK DR STE B
MARION VA
24354
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 276-378-3020
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008072
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4743
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: