Active NPI
Erich A Widemark, PHD, FNP-BC
- Family Nurse Practitioner
- Goodyear, AZ
National Provider Identifier
1669468260
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Nurse Practitioner
- License
- 083736
- Practice address
- 14415 W McDowell Rd
Goodyear
Goodyear, AZ 85395-2521 - Phone
- (623) 512-4190
- Fax
- (623) 512-4194
- NPI assigned
- Sep 20, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 083736 | AZ | Primary |
Addresses
Primary practice location
14415 W McDowell Rd
Goodyear
Goodyear, AZ 85395-2521
Mailing address
14415 W McDowell Rd
Suite D2
Goodyear, AZ 85395-2521
Phone (623) 512-4190
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 630344 | Medicaid | AZ | |
| 630344001 | Medicaid | AZ |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner, Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 083736 | AZ | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Neighborhood Family Practice PC | Past | Accepting new patients | |
| A H Chiropractic & Wellness LLC. | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1127174400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1258588800000",
"number": "1669468260",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14415 W MCDOWELL RD",
"address_2": "SUITE D2",
"city": "GOODYEAR",
"state": "AZ",
"postal_code": "853952521",
"telephone_number": "623-512-4190",
"fax_number": "623-512-4194"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14415 W MCDOWELL RD",
"address_2": "GOODYEAR",
"city": "GOODYEAR",
"state": "AZ",
"postal_code": "853952521",
"telephone_number": "623-512-4190",
"fax_number": "623-512-4194"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIDEMARK",
"first_name": "ERICH",
"middle_name": "A",
"credential": "PHD, FNP-BC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-09-20",
"last_updated": "2009-11-19",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "AZ",
"license": "083736",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "630344",
"state": "AZ"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "630344001",
"state": "AZ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Goodyear, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.