Provider Demographics
NPI:1659810190
Name:MELLO, WAGNER B
Entity Type:Individual
Prefix:
First Name:WAGNER
Middle Name:B
Last Name:MELLO
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 1:610 W 150TH ST APT 4J
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2400
Mailing Address - Country:US
Mailing Address - Phone:631-404-7073
Mailing Address - Fax:
Practice Address - Street 1:30 E. 49TH ST PENTHOUSE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1201
Practice Address - Country:US
Practice Address - Phone:631-404-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005922171100000X
NYF310958-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner