Basic Information
| Provider Information | |||||||||
| NPI: | 1629080437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIEGAND | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 W COWLES ST | ||||||||
| Address2: | CAIHC | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | 9074593811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 W COWLES ST | ||||||||
| Address2: | CAIHC | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | 9074593811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5143 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD05432 | 05 | AK | MEDICAID | P0080955 | 01 | AK | RAILROAD MEDICARE PIN# | OTHER |