Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD26173 | OR |
NPI | 1003805367 |
---|---|
Provider Name | William B Wignall |
First Address | Bend, OR 97701-3786 |
Second Address | Bend, OR 97701-3786 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2005 |
Last Update Date | 20/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01195239 | (05) | CO |
028100 | (05) | OR |
E36227 | (02) |