Provider Demographics
NPI:1235679739
Name:WIGGINTON, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:WIGGINTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 N MARY ELLA AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-7612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:FL
Practice Address - Zip Code:32404-6132
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26736225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant