Provider Demographics
NPI:1407241490
Name:WIGGERS, MARTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:WIGGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:SICKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-734-3535
Practice Address - Fax:503-734-3530
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172159363A00000X
ORPA172159363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500698025Medicaid
ORR186744OtherMEDICARE PTAN