Healthcare Provider Details

I. General information

NPI: 1891836409
Provider Name (Legal Business Name): JON PETER WIGERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 DOUGLAS AVE
HENNING MN
56551
US

IV. Provider business mailing address

PO BOX 16
HENNING MN
56551
US

V. Phone/Fax

Practice location:
  • Phone: 218-583-2953
  • Fax: 218-583-4521
Mailing address:
  • Phone: 218-583-2953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27216
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: