Provider Demographics
NPI:1285630848
Name:WANOUNOU, CHAIM (PA)
Entity Type:Individual
Prefix:
First Name:CHAIM
Middle Name:
Last Name:WANOUNOU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 RYDER ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4307
Mailing Address - Country:US
Mailing Address - Phone:718-253-0648
Mailing Address - Fax:
Practice Address - Street 1:100 ROSS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7672
Practice Address - Country:US
Practice Address - Phone:718-387-7628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007367363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4F8791Medicare ID - Type Unspecified
NYP39050Medicare UPIN