Provider Demographics
NPI:1851719025
Name:WIGGINS, GREGORY SHAUN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:SHAUN
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 S CREEK ST
Mailing Address - Street 2:APT. 215
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5515
Mailing Address - Country:US
Mailing Address - Phone:270-226-9206
Mailing Address - Fax:
Practice Address - Street 1:1020 S STATE HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4471
Practice Address - Country:US
Practice Address - Phone:830-997-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125240367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered