Provider Demographics
NPI:1295365179
Name:WIGHTMAN, SINJIN BREED (DPT)
Entity Type:Individual
Prefix:DR
First Name:SINJIN
Middle Name:BREED
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 NEW PALTZ RD APT 1
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-1040
Mailing Address - Country:US
Mailing Address - Phone:845-594-4112
Mailing Address - Fax:
Practice Address - Street 1:2 DELAVERGNE AVE
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-1202
Practice Address - Country:US
Practice Address - Phone:845-297-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty