Provider Demographics
NPI:1326686619
Name:WIGGINS, DEMARCUS G (BS, QBHP)
Entity Type:Individual
Prefix:
First Name:DEMARCUS
Middle Name:G
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:BS, QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3895 GEORGE ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-8251
Mailing Address - Country:US
Mailing Address - Phone:479-521-1532
Mailing Address - Fax:479-521-9940
Practice Address - Street 1:3895 GEORGE ANDERSON RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-8251
Practice Address - Country:US
Practice Address - Phone:479-521-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0000Medicaid
AR237641795Medicaid