Provider Demographics
NPI:1760988422
Name:WYSOCKI, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WYSOCKI
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 1:420 FAIRVIEW AVE APT 4D
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-3880
Mailing Address - Country:US
Mailing Address - Phone:201-564-8209
Mailing Address - Fax:
Practice Address - Street 1:139 FULTON ST RM 208
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2538
Practice Address - Country:US
Practice Address - Phone:212-513-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006169171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist