Provider Demographics
NPI:1427690304
Name:WEIGANT, MICHAEL DANIEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DANIEL
Last Name:WEIGANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HENSLEY DR LOT 15
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:KY
Mailing Address - Zip Code:40806-8382
Mailing Address - Country:US
Mailing Address - Phone:606-671-0032
Mailing Address - Fax:
Practice Address - Street 1:1203 AMERICAN GREETING CARD RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4811
Practice Address - Country:US
Practice Address - Phone:606-528-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator