Provider Demographics
NPI:1538789383
Name:WIGGINS, DEREK (PA-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WIGGINS
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 1:284 ALMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ALMONT
Mailing Address - State:MI
Mailing Address - Zip Code:48003-8601
Mailing Address - Country:US
Mailing Address - Phone:810-417-1056
Mailing Address - Fax:
Practice Address - Street 1:713 WINFIELD DUNN PKWY STE 9
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37876-5533
Practice Address - Country:US
Practice Address - Phone:865-429-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4837363A00000X
MI5601009759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4837OtherSTATE LICENCE
MI5601009759OtherSTATE LICENSE