Provider Demographics
NPI:1124355623
Name:POWERS, LIDWINA WANGSADIPURA (PA-C)
Entity type:Individual
Prefix:
First Name:LIDWINA
Middle Name:WANGSADIPURA
Last Name:POWERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:5510 SOUTHWEST DR STE 11-12
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8351
Practice Address - Country:US
Practice Address - Phone:870-641-4471
Practice Address - Fax:870-206-7068
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-753363A00000X
CAPA20529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR319542212Medicaid