Healthcare Provider Details

I. General information

NPI: 1053794115
Provider Name (Legal Business Name): DANA WIGHTMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 W JIMMIE LEEDS RD
POMONA NJ
08240
US

IV. Provider business mailing address

65 W JIMMIE LEEDS RD
POMONA NJ
08240-9102
US

V. Phone/Fax

Practice location:
  • Phone: 609-441-8146
  • Fax: 609-441-8002
Mailing address:
  • Phone: 609-441-8146
  • Fax: 609-441-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9108751
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9108751
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00475400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: