Basic Information
Provider Information | |||||||||
NPI: | 1053794115 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WIGHTMAN | ||||||||
FirstName: | DANA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 65 W JIMMIE LEEDS RD | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | NJ | ||||||||
PostalCode: | 082409102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6094418146 | ||||||||
FaxNumber: | 6094418002 | ||||||||
Practice Location | |||||||||
Address1: | 65 W JIMMIE LEEDS RD | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | NJ | ||||||||
PostalCode: | 08240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6094418146 | ||||||||
FaxNumber: | 6094418002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2015 | ||||||||
LastUpdateDate: | 09/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 9108751 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA9108751 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 25MP00475400 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.