Provider Demographics
NPI:1295744530
Name:WIGGINS, SHANNON GEORGEANN (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:GEORGEANN
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2310 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-4018
Mailing Address - Country:US
Mailing Address - Phone:517-346-7628
Mailing Address - Fax:517-346-7629
Practice Address - Street 1:2310 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4018
Practice Address - Country:US
Practice Address - Phone:517-346-7628
Practice Address - Fax:517-346-7629
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0853310215OtherBCN
MI114546319Medicaid
MI0853310215OtherBLUE CROSS
MIBW6551938OtherDEA NUMBER
MI0N88590001Medicare PIN
MIH36661Medicare UPIN
MIBW6551938OtherDEA NUMBER