Healthcare Provider Details

I. General information

NPI: 1295303725
Provider Name (Legal Business Name): CHARLETTE SHY WIGGINS-GURICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3161 WALNUT AVE
FREMONT CA
94538-2216
US

IV. Provider business mailing address

573 SE WALNUT ST APT 1
HILLSBORO OR
97123-4441
US

V. Phone/Fax

Practice location:
  • Phone: 510-796-1000
  • Fax:
Mailing address:
  • Phone: 408-841-1493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number64122
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: