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General NPI Number Information
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NPI Number | 1023993748
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Entity Type | Individual
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Provider Name | GREGORY WALLICK
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Gender | Male
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Dates
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Enumeration Date | 08/11/2025
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Last Update Date | 08/11/2025
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Provider Practice Location Address
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Address Line | 900 FRANKLIN AVE
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City | VALLEY STREAM
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State | NY
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Zip | 11580-2145
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Country | US
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Telephone | 516-256-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 27 GODFREY AVE
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City | BAYVILLE
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State | NY
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Zip | 11709-2711
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Country | US
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Telephone | 516-458-6811
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 2072246
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License Number State | NY
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