Provider Demographics
NPI:1871019554
Name:WENTZ, RICHARD PHILIP JR (RN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PHILIP
Last Name:WENTZ
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1976 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2813
Mailing Address - Country:US
Mailing Address - Phone:516-855-1800
Mailing Address - Fax:516-855-1811
Practice Address - Street 1:1976 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2813
Practice Address - Country:US
Practice Address - Phone:516-855-1800
Practice Address - Fax:516-855-1811
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY556814-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse