Provider Demographics
NPI:1912216581
Name:WIJESINGHE, SAMPATH (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMPATH
Middle Name:
Last Name:WIJESINGHE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5906
Mailing Address - Country:US
Mailing Address - Phone:559-583-4617
Mailing Address - Fax:559-583-4625
Practice Address - Street 1:1393 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657
Practice Address - Country:US
Practice Address - Phone:559-875-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21068363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical