Healthcare Provider Details

I. General information

NPI: 1902997091
Provider Name (Legal Business Name): DENNIS WAXMAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SULLIVAN AVE
FERNDALE NY
12734-4315
US

IV. Provider business mailing address

PO BOX 421 CRMC PHYSICIAN SERVICES
HARRIS NY
12742-0421
US

V. Phone/Fax

Practice location:
  • Phone: 845-292-6630
  • Fax: 845-794-9868
Mailing address:
  • Phone: 845-794-9864
  • Fax: 845-794-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001355
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: