Healthcare Provider Details

I. General information

NPI: 1801713623
Provider Name (Legal Business Name): BERT WU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 80 BOX 22177
APO AP
96367-0106
US

IV. Provider business mailing address

104 PINE DR
BLACK RIVER NY
13612-2110
US

V. Phone/Fax

Practice location:
  • Phone: 544-630-3044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number4745-4811-3813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: