Healthcare Provider Details

I. General information

NPI: 1275954190
Provider Name (Legal Business Name): NICOLAS WIEGAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 S HIGHWAY 94 SUITE 102
WELDON SPRING MO
63304-5610
US

IV. Provider business mailing address

5933 S HIGHWAY 94 SUITE 102
WELDON SPRING MO
63304-5610
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-5303
  • Fax:
Mailing address:
  • Phone: 314-479-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number46-4321873
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: