Healthcare Provider Details

I. General information

NPI: 1922322049
Provider Name (Legal Business Name): MICHELLE MONIQUE VANWICKLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 LONG BEACH RD
OCEANSIDE NY
11572-3240
US

IV. Provider business mailing address

3051 LONG BEACH RD
OCEANSIDE NY
11572-3240
US

V. Phone/Fax

Practice location:
  • Phone: 516-536-2000
  • Fax: 516-764-0257
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: