Healthcare Provider Details

I. General information

NPI: 1780112292
Provider Name (Legal Business Name): PAUL ANDREW WONTROSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2017
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK ST
NEW HAVEN CT
06504-8901
US

IV. Provider business mailing address

516 MAY DR
SCRANTON PA
18505-4310
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone: 570-344-8179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD470489
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: