Provider Demographics
NPI:1447974126
Name:WIGELY, COLLIN ROBERT (DPT)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:ROBERT
Last Name:WIGELY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 NUTMEG PL STE 111
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2557
Mailing Address - Country:US
Mailing Address - Phone:714-979-3500
Mailing Address - Fax:
Practice Address - Street 1:1520 NUTMEG PL STE 111
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2557
Practice Address - Country:US
Practice Address - Phone:714-979-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA302960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist