Basic Information
| Provider Information | |||||||||
| NPI: | 1013191071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1319 E 222ND ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104692601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186546358 | ||||||||
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| Practice Location | |||||||||
| Address1: | THIRD AVENUE AND 183RD STREET | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189609000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.