Provider Demographics
NPI:1265066179
Name:WIEGERINK, JAMES HAROLD
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:HAROLD
Last Name:WIEGERINK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-2209
Mailing Address - Country:US
Mailing Address - Phone:260-515-5778
Mailing Address - Fax:
Practice Address - Street 1:4824 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-2209
Practice Address - Country:US
Practice Address - Phone:260-515-5778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-29
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0500350517341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance