Healthcare Provider Details

I. General information

NPI: 1831379122
Provider Name (Legal Business Name): ELLEN A WIEGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 C STREET SUITE 550
SACRAMENTO CA
95816
US

IV. Provider business mailing address

3400 DATA DRIVE PHYSICIAN SUPPORT SERVICES
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-536-3200
  • Fax: 916-235-2182
Mailing address:
  • Phone: 916-379-2948
  • Fax: 916-858-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA105233
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberA105233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: