Basic Information
| Provider Information | |||||||||
| NPI: | 1942202635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGLEY | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 GAGE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993529532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5096272983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N 14TH AVE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095454800 | ||||||||
| FaxNumber: | 5095454861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/22/2006 | ||||||||
| NPIReactivationDate: | 03/28/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | MD00035873 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0602X | MD00035873 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207Y00000X | MD00035873 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 2041577 | 05 | WA | MEDICAID |