Provider Demographics
NPI:1346595923
Name:WANSOR, EDWARD A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:WANSOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PHEASANT LN
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-1326
Mailing Address - Country:US
Mailing Address - Phone:631-338-3282
Mailing Address - Fax:
Practice Address - Street 1:29 PHEASANT LN
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:NY
Practice Address - Zip Code:11933-1326
Practice Address - Country:US
Practice Address - Phone:631-338-3282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant