Healthcare Provider Details

I. General information

NPI: 1760950372
Provider Name (Legal Business Name): MARTHA R WASSERBAUER RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOUNTAIN VIEW PEDIATRICS 18 FEATHERS DRIVE
PLATTSBURGH NY
12901
US

IV. Provider business mailing address

MOUNTAIN VIEW PEDIATRICS 18 FEATHERS DRIVE
PLATTSBURGH NY
12901
US

V. Phone/Fax

Practice location:
  • Phone: 518-324-2040
  • Fax: 518-324-2041
Mailing address:
  • Phone: 518-324-2040
  • Fax: 518-324-2041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86094602
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: