Provider Demographics
NPI:1295303725
Name:WIGGINS-GURICH, CHARLETTE SHY
Entity type:Individual
Prefix:
First Name:CHARLETTE
Middle Name:SHY
Last Name:WIGGINS-GURICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 SE WALNUT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4441
Mailing Address - Country:US
Mailing Address - Phone:408-841-1493
Mailing Address - Fax:
Practice Address - Street 1:3161 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2216
Practice Address - Country:US
Practice Address - Phone:510-796-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR641222251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic