Provider Demographics
NPI:1306985643
Name:WIGMAN, EDITH LOSEY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:LOSEY
Last Name:WIGMAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:1987 BANKS SCHOOL ROAD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504
Mailing Address - Country:US
Mailing Address - Phone:252-520-2069
Mailing Address - Fax:
Practice Address - Street 1:2415 W VERNON AVENUE
Practice Address - Street 2:CASWELL CENTER
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504
Practice Address - Country:US
Practice Address - Phone:252-208-4066
Practice Address - Fax:252-208-4035
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC101945363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406105Medicaid