Provider Demographics
NPI:1730224924
Name:WIDASKI, ELIZABETH H (RN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:H
Last Name:WIDASKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:H
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4200 W MEMORIAL RD STE 410
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8305
Mailing Address - Country:US
Mailing Address - Phone:405-608-3866
Mailing Address - Fax:405-607-2976
Practice Address - Street 1:4200 W MEMORIAL RD STE 410
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8305
Practice Address - Country:US
Practice Address - Phone:405-608-3866
Practice Address - Fax:405-607-2976
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX632316363LA2200X
OK91951363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200197740AMedicaid
OK200197740AMedicaid
TX8J6218Medicare PIN
OK200197740Medicaid