Provider Demographics
NPI:1992090815
Name:WIEGLEY, NASIM (MD)
Entity type:Individual
Prefix:
First Name:NASIM
Middle Name:
Last Name:WIEGLEY
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-680-7634
Mailing Address - Fax:309-681-8620
Practice Address - Street 1:320 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-495-8614
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine