Provider Demographics
NPI:1053618173
Name:WIDMEYER, MERRY D (PA)
Entity type:Individual
Prefix:
First Name:MERRY
Middle Name:D
Last Name:WIDMEYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 3RD ST STE G
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-2861
Mailing Address - Country:US
Mailing Address - Phone:707-259-2000
Mailing Address - Fax:707-259-0181
Practice Address - Street 1:1001 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6413
Practice Address - Country:US
Practice Address - Phone:707-252-0494
Practice Address - Fax:707-252-7586
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10978363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ00607ZMedicare PIN