Provider Demographics
NPI:1790132926
Name:WIGGINS, CHERESA (DPT)
Entity Type:Individual
Prefix:
First Name:CHERESA
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12250 EL CAMINO REAL STE 190
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2298
Mailing Address - Country:US
Mailing Address - Phone:858-793-1460
Mailing Address - Fax:
Practice Address - Street 1:12250 EL CAMINO REAL STE 190
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2298
Practice Address - Country:US
Practice Address - Phone:858-793-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210203225100000X
CA294494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist