Provider Demographics
NPI:1831526060
Name:WIGTON, NICOLE M (PA C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:WIGTON
Suffix:
Gender:F
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 1:857 BRADDOCK LN
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1967
Mailing Address - Country:US
Mailing Address - Phone:801-216-4440
Mailing Address - Fax:
Practice Address - Street 1:155 W CANYON CREST RD STE 200
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1966
Practice Address - Country:US
Practice Address - Phone:801-763-9851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7607471-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical