Provider Demographics
NPI:1578720819
Name:VIGIL, JERRIANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:JERRIANN
Middle Name:
Last Name:VIGIL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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 76510
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80970-6510
Mailing Address - Country:US
Mailing Address - Phone:719-859-0015
Mailing Address - Fax:
Practice Address - Street 1:100 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-1910
Practice Address - Country:US
Practice Address - Phone:719-738-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0000939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73802832Medicaid