Healthcare Provider Details

I. General information

NPI: 1851732960
Provider Name (Legal Business Name): CHRISTIAN JOHN WIGFALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 10/25/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 HIDDEN VALLEY RD STE 200
CARLSBAD CA
92011-4219
US

IV. Provider business mailing address

6010 HIDDEN VALLEY RD STE 200
CARLSBAD CA
92011-4219
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-3000
  • Fax: 760-631-3016
Mailing address:
  • Phone: 760-631-3000
  • Fax: 760-631-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA23101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: