Provider Demographics
NPI:1417020090
Name:WASNIEWSKI, HOLLY (DO)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:WASNIEWSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:286 STAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:NY
Practice Address - Zip Code:12019-2618
Practice Address - Country:US
Practice Address - Phone:518-399-2101
Practice Address - Fax:518-399-2130
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02826373Medicaid
NY10118245OtherCDPHP
NY114976OtherGHI-HMO
NY200692OtherSENIOR WHOLE HEALTH
NY070302000106OtherFIDELIS
NY7213929OtherAETNA
NY000412554001OtherBSNENY
NY02826373Medicaid
NY7063U1OtherEMPIRE BC
NY4152743OtherMVP HEALTHCARE