| NPI | 1548635014 |
|---|---|
| Former Name | KELLY ALLEN WIDIGER |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12173) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: ND PAC0622) | |
| Enumeration Date | 2015-12-09 |
| Last Update Date | 2024-02-09 |