Provider Demographics
NPI:1043402357
Name:WANICH, NIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:NIYA
Middle Name:
Last Name:WANICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ENGLE STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-816-9800
Mailing Address - Fax:201-567-1569
Practice Address - Street 1:216 ENGLE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2444
Practice Address - Country:US
Practice Address - Phone:201-816-9800
Practice Address - Fax:201-567-1569
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230693207K00000X
CA104650207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology