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General NPI Number Information
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NPI Number | 1508875840
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Entity Type | Organization
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Legal Business Name | PROVISIONS HEALTH
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 12/11/2022
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Provider Practice Location Address
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Address Line | 2522 GOLF RD STE 2
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City | EAU CLAIRE
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State | WI
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Zip | 54701-6033
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Country | US
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Telephone | 715-833-0660
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Fax |
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Provider Business Mailing Address
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Address Line | 9557 S AIRPORT RD
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City | DEWITT
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State | MI
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Zip | 48820-9104
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | SHANNON WIGGINS
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Credential | D.O.
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Telephone | 517-346-7628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101013727
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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