Provider Demographics
NPI:1760642839
Name:WIGGERS, ANDREW (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WIGGERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:SUITE 450
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-672-4568
Mailing Address - Fax:309-672-4569
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 450
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-672-4568
Practice Address - Fax:309-672-4569
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01162435OtherRR MEDICARE
IL537460010Medicare PIN