Healthcare Provider Details

I. General information

NPI: 1568462794
Provider Name (Legal Business Name): JANET WYNNE-BROSIUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE SUITE 200N
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

19 BRADHURST AVE SUITE 200N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7701
  • Fax: 914-345-0652
Mailing address:
  • Phone: 914-493-7701
  • Fax: 914-345-0652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006717
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: