Healthcare Provider Details

I. General information

NPI: 1831911395
Provider Name (Legal Business Name): NEXT WAVE PEDIATRIC ENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 ROUTE 70 E STE 1
CHERRY HILL NJ
08003-2141
US

IV. Provider business mailing address

1940 ROUTE 70 E STE 1
CHERRY HILL NJ
08003-2141
US

V. Phone/Fax

Practice location:
  • Phone: 609-696-5929
  • Fax: 609-696-5619
Mailing address:
  • Phone: 609-696-5929
  • Fax: 609-696-5619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN D WALKER
Title or Position: OWNER
Credential: MD
Phone: 609-696-5929