Provider Demographics
NPI:1215905427
Name:MAXWELL-WIGGINS, JASON R (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:MAXWELL-WIGGINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:R
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108
Practice Address - Country:US
Practice Address - Phone:651-641-6200
Practice Address - Fax:651-641-6205
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45055208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H76650Medicare UPIN