MEDICARE: MR. WIDMARK ROY DWYER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	T520553726280	FL

General Provider Information

NPI Number	:	1386188159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WIDMARK ROY DWYER

Provider Business Mailing Address
First Line	:	22 UNICORN CT
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5760
Country	:	US
Telephone Number	:	561-692-1925
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 UNICORN CT
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5760
Country	:	US
Telephone Number	:	561-692-1925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2016
Last Update Date	:	12/13/2016

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