Healthcare Provider Details

I. General information

NPI: 1003666470
Provider Name (Legal Business Name): AEDEN J LIGON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9216 CRYSTAL SPRING DR
FORT WAYNE IN
46804-6510
US

IV. Provider business mailing address

9216 CRYSTAL SPRING DR
FORT WAYNE IN
46804-6510
US

V. Phone/Fax

Practice location:
  • Phone: 765-480-9828
  • Fax:
Mailing address:
  • Phone: 765-480-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number36003793A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: