Provider Demographics
NPI:1083107452
Name:WIGGINTON, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:WIGGINTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-543-6979
Mailing Address - Fax:314-364-6321
Practice Address - Street 1:2708 S RIFE MEDICAL LN STE 130
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1455
Practice Address - Country:US
Practice Address - Phone:479-338-5555
Practice Address - Fax:479-338-5533
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09485207Q00000X
ARE-16541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine