Derek Widener, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

6568 Issued in CA

Practice address

1221 N Dutton Ave
Santa Rosa, CA 95401-4607

Phone

(707) 543-8360

NPI assigned

Dec 30, 2011

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1325203200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1325203200000",
    "number": "1154691624",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1221 N DUTTON AVE",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954014607"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1221 N DUTTON AVE",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954014607",
            "telephone_number": "707-543-8360"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDENER",
        "first_name": "DEREK",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-12-30",
        "last_updated": "2011-12-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "CA",
            "license": "6568",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Gayle Whitlock
• Lucy Whitney
• Derek Edward Whittington, CATC IV
• John William Wickenburg, P.T.
• Margaret Wideau
• Jennifer Widerhorn
• Ellie Rivkah Pritschet Wiener
• Makayla Danielle Wietek
• Wallace T. Wiggam, RN
• Katharine Wignall, RN

• Physical Therapy Assistant in Santa Rosa, CA
• Providers in Santa Rosa, CA by specialty
• Physical Therapy Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 30, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.