Provider Demographics
NPI:1831287952
Name:WIEGAND, LYNN T (PST)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:T
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:PST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 HARRISON ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3096
Mailing Address - Country:US
Mailing Address - Phone:315-464-6312
Mailing Address - Fax:315-464-6482
Practice Address - Street 1:550 HARRISON ST
Practice Address - Street 2:STE. 100
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3096
Practice Address - Country:US
Practice Address - Phone:315-464-6312
Practice Address - Fax:315-464-6482
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004174-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist