MEDICARE: MICHAEL EDWARD WIEGERT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	003590	GA
2	363A00000X	Physician Assistant	0010-05316	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104822592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL EDWARD WIEGERT PA-C

Provider Business Mailing Address
First Line	:	PO BOX 603949
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-3949
Country	:	US
Telephone Number	:	919-350-8991
Fax Number	:	919-350-7687

Provider Business Practice Location Address
First Line	:	3000 NEW BERN AVE STE 2035
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27610-1231
Country	:	US
Telephone Number	:	919-231-6132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	10/01/2024

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