Provider Demographics
NPI:1487979977
Name:WIGETMAN, SUSAN (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WIGETMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CALLE PORTAL STE B260
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2982
Mailing Address - Country:US
Mailing Address - Phone:520-226-4338
Mailing Address - Fax:
Practice Address - Street 1:77 CALLE PORTAL STE B260
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2982
Practice Address - Country:US
Practice Address - Phone:520-226-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2263101367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ938258Medicaid
AZ938258Medicaid
MA001559901Medicare PIN