Provider Demographics
NPI:1609137504
Name:WIGNER, NATHAN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW
Last Name:WIGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 SOMMERSET ARC
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-1717
Mailing Address - Country:US
Mailing Address - Phone:206-819-5461
Mailing Address - Fax:
Practice Address - Street 1:4351 E LOHMAN AVE STE 301
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8262
Practice Address - Country:US
Practice Address - Phone:575-532-9755
Practice Address - Fax:575-532-8881
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60738147207XS0117X
NMMD2022-1319207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8966595OtherMEDICARE PIN
WA1609137504Medicaid