MEDICARE: MRS. CAROL ANN WAXMAN RPAC

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	0018351	NY

General Provider Information

NPI Number	:	1326060906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL ANN WAXMAN RPAC

Provider Business Mailing Address
First Line	:	108 HALL ROAD
Second Line	:
City	:	GRAHAMSVILLE
State	:	NY
Zip	:	12740-9749
Country	:	US
Telephone Number	:	845-985-7304
Fax Number	:

Provider Business Practice Location Address
First Line	:	4504 STATE ROUTE 55
Second Line	:
City	:	SWAN LAKE
State	:	NY
Zip	:	12783
Country	:	US
Telephone Number	:	845-292-6875
Fax Number	:	845-292-4873

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	07/08/2007

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