MEDICARE: MICHELLE RAE WIGGINS PTA

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	225200000X	Physical Therapy Assistant	A-0962	NM

General Provider Information

NPI Number	:	1255764247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE RAE WIGGINS PTA

Provider Business Mailing Address
First Line	:	7108 HEARTHSTONE RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-4583
Country	:	US
Telephone Number	:	210-275-9968
Fax Number	:

Provider Business Practice Location Address
First Line	:	7108 HEARTHSTONE RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-4583
Country	:	US
Telephone Number	:	210-275-9968
Fax Number	:

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

Provider Enumeration Date	:	08/14/2013
Last Update Date	:	08/14/2013

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Directions to “ MICHELLE RAE WIGGINS PTA” Practice Location

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