Healthcare Provider Details

I. General information

NPI: 1447414909
Provider Name (Legal Business Name): SHARON ANN WYSE L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MADISON AVE SUITE #508
NEW YORK NY
10016-0801
US

IV. Provider business mailing address

4248 64TH ST APT 3
WOODSIDE NY
11377-5047
US

V. Phone/Fax

Practice location:
  • Phone: 917-603-8081
  • Fax:
Mailing address:
  • Phone: 917-603-8081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number02447
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: