Provider Demographics
NPI:1760950372
Name:WASSERBAUER, MARTHA R (RDN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:R
Last Name:WASSERBAUER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MOUNTAIN VIEW PEDIATRICS
Mailing Address - Street 2:18 FEATHERS DRIVE
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-324-2040
Mailing Address - Fax:518-324-2041
Practice Address - Street 1:MOUNTAIN VIEW PEDIATRICS
Practice Address - Street 2:18 FEATHERS DRIVE
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-324-2040
Practice Address - Fax:518-324-2041
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86094602136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered