Provider Demographics
NPI:1568462794
Name:WYNNE-BROSIUS, JANET (PA)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:WYNNE-BROSIUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE
Mailing Address - Street 2:SUITE 200N
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-493-7701
Mailing Address - Fax:914-345-0652
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:SUITE 200N
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-7701
Practice Address - Fax:914-345-0652
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400066198OtherMEDICARE PTAN
NYA400066199OtherMEDICARE PTAN
NY02085894Medicaid