Healthcare Provider Details

I. General information

NPI: 1821919440
Provider Name (Legal Business Name): MICHAEL TYLER WAFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FLATBUSH AVENUE EXT
BROOKLYN NY
11201-2903
US

IV. Provider business mailing address

36 MACON ST
BROOKLYN NY
11216-2107
US

V. Phone/Fax

Practice location:
  • Phone: 718-215-1818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: