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General NPI Number Information
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NPI Number | 1174908446
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Entity Type | Individual
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Provider Name | VIVIAN WIATER PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 04/24/2017
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Provider Practice Location Address
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Address Line | 333 CEDAR ST STE TMP 4
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City | NEW HAVEN
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State | CT
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Zip | 06510-3206
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Country | US
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Telephone | 203-737-2096
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Fax |
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Provider Business Mailing Address
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Address Line | 333 CEDAR ST STE TMP 4
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City | NEW HAVEN
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State | CT
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Zip | 06510-3206
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Country | US
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Telephone | 203-737-2096
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3393
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License Number State | CT
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