Provider Demographics
NPI:1063639169
Name:WHARTON, PETER E (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:E
Last Name:WHARTON
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 KNOLLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1551
Mailing Address - Country:US
Mailing Address - Phone:631-421-0502
Mailing Address - Fax:
Practice Address - Street 1:300 BAYSHORE ROAD
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703
Practice Address - Country:US
Practice Address - Phone:631-586-2700
Practice Address - Fax:631-491-8799
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant