Provider Demographics
NPI:1003122169
Name:WIRGAU, JEFFERY DALE (PAC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:DALE
Last Name:WIRGAU
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3267 W NICHOLSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:OSSINEKE
Mailing Address - State:MI
Mailing Address - Zip Code:49766-9722
Mailing Address - Country:US
Mailing Address - Phone:989-590-1977
Mailing Address - Fax:
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005846363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical