Provider Demographics
NPI:1457728602
Name:HEWA WICRAMA ARACHCHILAGE, GAYAN SAMPATH WIJEWA
Entity Type:Individual
Prefix:
First Name:GAYAN SAMPATH WIJEWA
Middle Name:
Last Name:HEWA WICRAMA ARACHCHILAGE
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 1:139-38 87TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRAIRWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:315-244-4516
Mailing Address - Fax:
Practice Address - Street 1:13938 87TH AVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-3018
Practice Address - Country:US
Practice Address - Phone:315-244-4516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009972-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant