Provider Demographics
NPI:1780783373
Name:WOLFE, DWAN SIGGERS (NP)
Entity type:Individual
Prefix:
First Name:DWAN
Middle Name:SIGGERS
Last Name:WOLFE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DWAN
Other - Middle Name:SIGGERS
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1500 E. WOODROW WILSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5199
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-368-3917
Practice Address - Street 1:1500 E. WOODROW WILSON DRIVE
Practice Address - Street 2:PRIMARY CARE BLUE II CLINIC
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-3917
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR785196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily