Provider Demographics
NPI:1033965215
Name:WIGHT, LAUREN ADELE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ADELE
Last Name:WIGHT
Suffix:
Gender:
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 1:603 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49073-9210
Mailing Address - Country:US
Mailing Address - Phone:480-489-4475
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST # 74
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-27
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant