Healthcare Provider Details

I. General information

NPI: 1053321935
Provider Name (Legal Business Name): GEORGE E WIGGINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DEER RUN RD
MARION IL
62959-8948
US

IV. Provider business mailing address

12266 DEER RUN RD
MARION IL
62959-8948
US

V. Phone/Fax

Practice location:
  • Phone: 618-964-1223
  • Fax:
Mailing address:
  • Phone: 618-525-1649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1075328/1932A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: