Healthcare Provider Details

I. General information

NPI: 1831526060
Provider Name (Legal Business Name): NICOLE M WIGTON PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 W CANYON CREST RD STE 200
ALPINE UT
84004-1966
US

IV. Provider business mailing address

857 BRADDOCK LN
ALPINE UT
84004-1967
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-9851
  • Fax:
Mailing address:
  • Phone: 801-216-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7607471-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: