Provider Demographics
NPI:1326609934
Name:WIEGAND, NICHOLAS MARTIN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARTIN
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 WHISPERING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-5826
Mailing Address - Country:US
Mailing Address - Phone:314-479-0628
Mailing Address - Fax:
Practice Address - Street 1:600 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3433
Practice Address - Country:US
Practice Address - Phone:636-327-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170262112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer