Basic Information
| Provider Information | |||||||||
| NPI: | 1932739141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGGAM | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 PROFESSIONAL DR # CA | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075443295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2403 PROFESSIONAL DR # CA | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075443295 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 307469 | CA | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.