Provider Demographics
NPI:1851755649
Name:WASIK, KRAIG KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:KENNETH
Last Name:WASIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MARSHALL WAY DEPT OF
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6533
Mailing Address - Country:US
Mailing Address - Phone:530-622-1441
Mailing Address - Fax:
Practice Address - Street 1:47 NEW SCOTLAND AVENUE
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63818390200000X
CA17357207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program