Provider Demographics
NPI:1689636870
Name:WICKREMESINGHE, PRASANNA C (MD, FACP)
Entity Type:Individual
Prefix:DR
First Name:PRASANNA
Middle Name:C
Last Name:WICKREMESINGHE
Suffix:
Gender:M
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2103
Mailing Address - Country:US
Mailing Address - Phone:718-448-0865
Mailing Address - Fax:718-816-8065
Practice Address - Street 1:481 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2103
Practice Address - Country:US
Practice Address - Phone:718-448-0865
Practice Address - Fax:718-816-8065
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115502174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist