Provider Demographics
NPI:1003245044
Name:WIGLE, MICHAEL EUGENE (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EUGENE
Last Name:WIGLE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-9049
Mailing Address - Country:US
Mailing Address - Phone:208-618-0787
Mailing Address - Fax:208-618-0796
Practice Address - Street 1:925 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9049
Practice Address - Country:US
Practice Address - Phone:208-618-0787
Practice Address - Fax:208-618-0796
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1346A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner