MEDICARE: WANDA HERCULES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1659816783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA HERCULES

Provider Business Mailing Address
First Line	:	569 EASTERN PKWY
Second Line	:	3RD FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11216-4405
Country	:	US
Telephone Number	:	347-385-3351
Fax Number	:

Provider Business Practice Location Address
First Line	:	569 EASTERN PKWY
Second Line	:	3RD FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11216-4405
Country	:	US
Telephone Number	:	347-385-3351
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	12/28/2016

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Directions to “ WANDA HERCULES ” Practice Location

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