Provider Demographics
NPI:1659045235
Name:KANISHKA, WALLIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:WALLIE
Middle Name:
Last Name:KANISHKA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HITCHING POST LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1625
Mailing Address - Country:US
Mailing Address - Phone:801-918-4155
Mailing Address - Fax:
Practice Address - Street 1:25 HITCHING POST LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1625
Practice Address - Country:US
Practice Address - Phone:801-918-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program