Basic Information
| Provider Information | |||||||||
| NPI: | 1902997091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAXMAN | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | CRMC PHYSICIAN SERVICES | ||||||||
| City: | HARRIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127420421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457949864 | ||||||||
| FaxNumber: | 8457949868 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127344315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452926630 | ||||||||
| FaxNumber: | 8457949868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001355 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 01969891 | 05 | NY | MEDICAID |