Provider Demographics
NPI:1245780832
Name:WYSOCKI, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4142
Mailing Address - Country:US
Mailing Address - Phone:718-819-6805
Mailing Address - Fax:347-841-9109
Practice Address - Street 1:530 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2140
Practice Address - Country:US
Practice Address - Phone:201-523-9207
Practice Address - Fax:201-523-9208
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00754700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ255015Medicare PIN