Basic Information
| Provider Information | |||||||||
| NPI: | 1679556112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIJTMANS | ||||||||
| FirstName: | ERIK | ||||||||
| MiddleName: | HJALMAR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5982 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234710982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574747490 | ||||||||
| FaxNumber: | 7574747931 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 KEMPSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574747490 | ||||||||
| FaxNumber: | 7574747931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 10/22/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305003781 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 010417481 | 05 | VA | MEDICAID | 010417465 | 05 | VA | MEDICAID | 008938768 | 05 | VA | MEDICAID | 010405602 | 05 | VA | MEDICAID | 010417473 | 05 | VA | MEDICAID | 1679556112 | 05 | VA | MEDICAID |