Healthcare Provider Details

I. General information

NPI: 1942202635
Provider Name (Legal Business Name): TERRY LEE WIGLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date: 03/22/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

1200 N 14TH AVE SUITE 350
PASCO WA
99301
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-545-4800
  • Fax: 509-545-4861
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD00035873
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberMD00035873
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD00035873
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: