Basic Information
| Provider Information | |||||||||
| NPI: | 1528471687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAKSZUL | ||||||||
| FirstName: | EPHRAIM | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 WOODLAND ST STE 23 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061052368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605222251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 WOODLAND ST STE 23 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061052368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605222251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3330 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 3330 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 25MP00336900 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 23 017623 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.