Healthcare Provider Details

I. General information

NPI: 1447540349
Provider Name (Legal Business Name): MATTHEW DAVID WASIELEWSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PINE AVE
ERIE PA
16504-2316
US

IV. Provider business mailing address

4500 PINE AVE
ERIE PA
16504-2316
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-5800
  • Fax: 814-877-5809
Mailing address:
  • Phone: 814-877-5800
  • Fax: 814-877-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS016668
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: