Provider Demographics
NPI:1891426292
Name:WIGNALL, AIZA C (ARNP)
Entity Type:Individual
Prefix:
First Name:AIZA
Middle Name:C
Last Name:WIGNALL
Suffix:
Gender:F
Credentials:ARNP
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1101 MADISON ST
Practice Address - Street 2:STE 900
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-4379
Practice Address - Country:US
Practice Address - Phone:206-215-6800
Practice Address - Fax:206-215-6801
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60753022163W00000X
WAAP61283823363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2214788Medicaid