MEDICARE: CHAYA D WALD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	012036	NY

General Provider Information

NPI Number	:	1255529350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAYA D WALD PA

Provider Business Mailing Address
First Line	:	1965 52ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1732
Country	:	US
Telephone Number	:	917-754-7754
Fax Number	:

Provider Business Practice Location Address
First Line	:	4819 14TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-3119
Country	:	US
Telephone Number	:	718-438-0707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	10/15/2007

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Directions to “ CHAYA D WALD PA” Practice Location

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