Healthcare Provider Details

I. General information

NPI: 1194905083
Provider Name (Legal Business Name): JASON J WYLAND PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE EMERGENCY DEPT
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

550 1ST AVE EMERGENCY DEPT
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 646-501-9946
  • Fax: 646-501-9790
Mailing address:
  • Phone: 646-501-9946
  • Fax: 646-501-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2411
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: