Provider Demographics
NPI:1962419770
Name:WIGGINS, KIM CHERI (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:CHERI
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:738 N COLLEGE RD
Practice Address - Street 2:SUITE C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3385
Practice Address - Country:US
Practice Address - Phone:208-814-7100
Practice Address - Fax:208-737-2731
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9039208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00899548OtherMCRR
ID1962419770Medicaid
IDP00899548OtherMCRR
ID1962419770Medicaid