Provider Demographics
NPI:1992736243
Name:WIGLEY, SUSAN (DC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WIGLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 MOORPARK AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1714
Mailing Address - Country:US
Mailing Address - Phone:408-295-9970
Mailing Address - Fax:
Practice Address - Street 1:4155 MOORPARK AVE STE 21
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1714
Practice Address - Country:US
Practice Address - Phone:408-295-9970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17746111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU72586Medicare UPIN
CADC0177460Medicare ID - Type Unspecified