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General NPI Number Information
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NPI Number | 1962831354
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Entity Type | Individual
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Provider Name | SAMUEL LAWRENCE WIDDOWSON FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 09/20/2016
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Provider Practice Location Address
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Address Line | 3676 PARKER BLVD
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City | PUEBLO
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State | CO
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Zip | 81008-2212
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Country | US
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Telephone | 484-619-1973
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Fax |
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Provider Business Mailing Address
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Address Line | 3676 PARKER BLVD
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City | PUEBLO
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State | CO
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Zip | 81008-2212
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Country | US
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Telephone | 484-619-1973
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | SP013311
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APN.0991213-NP
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License Number State | CO
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