Basic Information
| Provider Information | |||||||||
| NPI: | 1003245044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGLE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838549049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086180787 | ||||||||
| FaxNumber: | 2086180796 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838549049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086180787 | ||||||||
| FaxNumber: | 2086180796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-1346A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.