Provider Demographics
NPI:1194885293
Name:WIGHTMAN-HENTZ, SUSAN M (APN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:WIGHTMAN-HENTZ
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34TH STREET AND CIVIC CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-590-1719
Mailing Address - Fax:215-590-1771
Practice Address - Street 1:34TH STREET AND CIVIC CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1719
Practice Address - Fax:215-590-1771
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN280126L363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid
PENDINGMedicare UPIN
PAPENDINGMedicaid