Provider Demographics
NPI:1053185918
Name:HUMPHRIES WIDGER, JAMIE KEHAULANI (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:KEHAULANI
Last Name:HUMPHRIES WIDGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15625 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1627
Mailing Address - Country:US
Mailing Address - Phone:562-902-3000
Mailing Address - Fax:562-902-9593
Practice Address - Street 1:15625 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1627
Practice Address - Country:US
Practice Address - Phone:562-902-3000
Practice Address - Fax:562-902-9593
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant