Provider Demographics
NPI:1518467844
Name:PATTERSON, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:PATTERSON
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 1:15608 RIVERSIDE DR W APT 5J
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-7008
Mailing Address - Country:US
Mailing Address - Phone:929-810-8783
Mailing Address - Fax:
Practice Address - Street 1:25 AVENUE D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-6935
Practice Address - Country:US
Practice Address - Phone:646-395-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY135562210Medicaid