Provider Demographics
NPI:1457729097
Name:WIGDAHL, JOSHUA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WIGDAHL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 E MESITA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-3738
Mailing Address - Country:US
Mailing Address - Phone:316-200-2080
Mailing Address - Fax:
Practice Address - Street 1:606 N MULBERRY RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3532
Practice Address - Country:US
Practice Address - Phone:316-788-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant