Healthcare Provider Details

I. General information

NPI: 1336570589
Provider Name (Legal Business Name): SLEEP DISORDERS LAB OF CENTRAL NEW YORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CHAMPLIN AVE SUITE 1
UTICA NY
13502-3662
US

IV. Provider business mailing address

1450 CHAMPLIN AVE SUITE 1
UTICA NY
13502-3662
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-9004
  • Fax:
Mailing address:
  • Phone: 315-624-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number207857
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ANWAR WASSEL
Title or Position: AUTHORIZED SIGNER
Credential: MD
Phone: 315-542-4582