Provider Demographics
NPI:1316793870
Name:WILGUS, SAMANTHA JAYNE (DPM)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JAYNE
Last Name:WILGUS
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6070
Mailing Address - Country:US
Mailing Address - Phone:970-810-2847
Mailing Address - Fax:970-810-2774
Practice Address - Street 1:1600 23RD AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6070
Practice Address - Country:US
Practice Address - Phone:970-810-2847
Practice Address - Fax:970-810-2774
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDT.000632390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program