Provider Demographics
NPI:1891836409
Name:WIGERT, JON PETER (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:PETER
Last Name:WIGERT
Suffix:
Gender:M
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:PO BOX 16
Mailing Address - Street 2:
Mailing Address - City:HENNING
Mailing Address - State:MN
Mailing Address - Zip Code:56551
Mailing Address - Country:US
Mailing Address - Phone:218-583-2953
Mailing Address - Fax:
Practice Address - Street 1:401 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:HENNING
Practice Address - State:MN
Practice Address - Zip Code:56551
Practice Address - Country:US
Practice Address - Phone:218-583-2953
Practice Address - Fax:218-583-4521
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D49060Medicare UPIN
MN89002393Medicare ID - Type Unspecified