Provider Demographics
NPI:1477929123
Name:HERATH, H M CHATHURAN WIKUM
Entity Type:Individual
Prefix:MR
First Name:H M CHATHURAN WIKUM
Middle Name:
Last Name:HERATH
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 1:13938 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-3018
Mailing Address - Country:US
Mailing Address - Phone:315-244-8192
Mailing Address - Fax:
Practice Address - Street 1:34 CORNELL DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1037
Practice Address - Country:US
Practice Address - Phone:315-386-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009973-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant