Basic Information
| Provider Information | |||||||||
| NPI: | 1952052243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDEMAN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117287 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394328331 | ||||||||
| FaxNumber: | 8133211296 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 HARMONY PARK CIR | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719135417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016247700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2022 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 216236 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.