Healthcare Provider Details

I. General information

NPI: 1528040326
Provider Name (Legal Business Name): MICHAEL G WIGGINS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 ARLINGTON DR
VIDALIA GA
30474-7209
US

IV. Provider business mailing address

205 ARLINGTON DR
VIDALIA GA
30474-7209
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-2530
  • Fax: 912-537-9668
Mailing address:
  • Phone: 912-537-2530
  • Fax: 912-537-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR102724
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: