Provider Demographics
NPI:1013070440
Name:WRIGLEY, KIM C (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:C
Last Name:WRIGLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 MEMORIAL DR STE 340
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5373
Mailing Address - Country:US
Mailing Address - Phone:618-234-9884
Mailing Address - Fax:
Practice Address - Street 1:4700 MEMORIAL DR STE 340
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5373
Practice Address - Country:US
Practice Address - Phone:618-234-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002475363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P58943Medicare UPIN
ILK34727Medicare ID - Type Unspecified