Basic Information
| Provider Information | |||||||||
| NPI: | 1679738512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIGGINS | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | 4809614605 | ||||||||
| Practice Location | |||||||||
| Address1: | 21001 N TATUM BLVD STE 74-1570 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850505228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805389811 | ||||||||
| FaxNumber: | 4805389809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 152W00000X | 952 | NV | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1626 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.