Provider Demographics
NPI:1275954190
Name:WIEGAND, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5933 S HIGHWAY 94
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-5610
Mailing Address - Country:US
Mailing Address - Phone:314-479-5303
Mailing Address - Fax:
Practice Address - Street 1:5933 S HIGHWAY 94
Practice Address - Street 2:SUITE 102
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-5610
Practice Address - Country:US
Practice Address - Phone:314-479-5303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO46-4321873332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies