Basic Information
| Provider Information | |||||||||
| NPI: | 1184647034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIGGINS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5155 E. EAGLE DRIVE | ||||||||
| Address2: | #20730 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852773031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
| FaxNumber: | 4807042690 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 E. PRESIDIO STREET | ||||||||
| Address2: | #101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852151165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
| FaxNumber: | 4804611785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1453 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.