Healthcare Provider Details

I. General information

NPI: 1104897974
Provider Name (Legal Business Name): LAWRENCE WIGGINS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2361 PAYSPHERE CIR
CHICAGO IL
60674-0023
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099-2676
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-4358
  • Fax:
Mailing address:
  • Phone: 847-872-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: