Provider Demographics
NPI:1215904495
Name:WIGLEY, KENNON D (MD)
Entity type:Individual
Prefix:
First Name:KENNON
Middle Name:D
Last Name:WIGLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2700 E 29TH STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:979-774-4008
Mailing Address - Fax:979-774-7893
Practice Address - Street 1:2700 E 29TH STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-774-4008
Practice Address - Fax:979-774-7893
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2011-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG5771207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease