1013166453 NPI number — MS. STEPHANIE RUSSELL WIEGAND MSPT

Table of content: MS. STEPHANIE RUSSELL WIEGAND MSPT (NPI 1013166453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013166453 NPI number — MS. STEPHANIE RUSSELL WIEGAND MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEGAND
Provider First Name:
STEPHANIE
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSSELL
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
CELENE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013166453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 N WYATT DR
Provider Second Line Business Mailing Address:
SUITE #130
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712-6115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-784-6570
Provider Business Mailing Address Fax Number:
520-784-6574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 N WYATT DR
Provider Second Line Business Practice Location Address:
SUITE #130
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-6115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-784-6570
Provider Business Practice Location Address Fax Number:
520-784-6574
Provider Enumeration Date:
09/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5586 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , with the licence number: 5586 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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