Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | NP-1346A | ID |
NPI | 1003245044 |
---|---|
Provider Name | Michael Eugene Wigle |
First Address | Post Falls, ID 83854-9049 |
Second Address | Post Falls, ID 83854-9049 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2013 |
Last Update Date | 27/08/2017 |