Provider Demographics
NPI:1679330542
Name:WIDGER, TYLER (FNP)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WIDGER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3747 45TH ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3747 45TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-3008
Practice Address - Country:US
Practice Address - Phone:219-923-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015019A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily