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General NPI Number Information
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NPI Number | 1720221211
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Entity Type | Individual
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Provider Name | LYLITH SKYE WIDMER M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 09/26/2018
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Provider Practice Location Address
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Address Line | 131 1ST AVE
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City | HAINES
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State | AK
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Zip | 99827
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Country | US
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Telephone | 907-766-6335
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1782
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City | HAINES
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State | AK
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Zip | 99827-1782
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Country | US
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Telephone | 907-766-6335
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 7648
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License Number State | AK
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Legacy Identifiers
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Identifier #1
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Identifier Code | 1571200
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Identifier Type | MEDICAID
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Identifier State | AK
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 1571200
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Identifier Type | MEDICAID
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Identifier State | AK
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Identifier Issuer |
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