Provider Demographics
NPI:1629080437
Name:WIEGAND, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W COWLES ST
Mailing Address - Street 2:CAIHC
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:907-459-3811
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:CAIHC
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:907-459-3811
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD05432Medicaid
AKP0080955OtherRAILROAD MEDICARE PIN#
AKMD05432Medicaid
G97961Medicare UPIN