MEDICARE: DANA WIGHTMAN PAC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA9108751	FL

General Provider Information

NPI Number	:	1730548959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANA WIGHTMAN PAC, PLLC

Provider Business Mailing Address
First Line	:	253 NE 2ND ST
Second Line	:	APT 1603
City	:	MIAMI
State	:	FL
Zip	:	33132-2292
Country	:	US
Telephone Number	:	908-399-4987
Fax Number	:

Provider Business Practice Location Address
First Line	:	253 NE 2ND ST
Second Line	:	APT 1603
City	:	MIAMI
State	:	FL
Zip	:	33132-2292
Country	:	US
Telephone Number	:	908-399-4987
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN ASSISTANT
Name	:	MRS. DANA WIGHTMAN
Credential	:	PA-C
Telephone Number	:	908-399-4987

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	02/16/2016

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