Provider Demographics
NPI:1972567642
Name:WIEGAN, LAURA W (MSPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:W
Last Name:WIEGAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 CUTSHAW AVE
Mailing Address - Street 2:SUITE 299
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230
Mailing Address - Country:US
Mailing Address - Phone:804-340-1193
Mailing Address - Fax:804-340-1930
Practice Address - Street 1:9516 CRAIGS MILL DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3555
Practice Address - Country:US
Practice Address - Phone:804-965-6232
Practice Address - Fax:804-545-2806
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6400713OtherUNITED HEALTHCARE
329180OtherMAMSI
183574OtherANTHEM PPO
54960OtherMEDICAID HMO
15291354OtherAETNA
183574OtherHEALTHKEEPERS
183531OtherANTHEM PPO
6404543OtherUNITED HEALTHCARE
15291354OtherAETNA HMO
429180OtherMAMSI
255534OtherSOUTHERN HEALTH
183574OtherHEALTHKEEPERS
429180OtherMAMSI
54960OtherMEDICAID HMO
008569R47Medicare ID - Type Unspecified
329180OtherMAMSI