Provider Demographics
NPI:1922206689
Name:WIEGMAN, CORY JAMES (PTA)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:JAMES
Last Name:WIEGMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 LITCHFIELD AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3003
Mailing Address - Country:US
Mailing Address - Phone:320-235-2946
Mailing Address - Fax:
Practice Address - Street 1:1115 LITCHFIELD AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3003
Practice Address - Country:US
Practice Address - Phone:320-235-2946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant