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General NPI Number Information
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NPI Number | 1922690304
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Entity Type | Individual
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Provider Name | TYLER WIGGINS PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/08/2021
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Last Update Date | 02/08/2021
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Provider Practice Location Address
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Address Line | 4777 E OUTER DR STE 1147
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City | DETROIT
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State | MI
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Zip | 48234-3241
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Country | US
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Telephone | 810-602-8898
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Fax |
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Provider Business Mailing Address
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Address Line | 284 ALMONT AVE
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City | ALMONT
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State | MI
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Zip | 48003-8601
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Country | US
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Telephone | 810-602-8898
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601010433
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License Number State | MI
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