Provider Demographics
NPI:1922108760
Name:WADLER, JEFFREY R (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:WADLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 COLUMBIA ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2306
Mailing Address - Country:US
Mailing Address - Phone:518-751-1016
Mailing Address - Fax:
Practice Address - Street 1:52 SHOPRITE BLVD
Practice Address - Street 2:ROUTE 209
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-5632
Practice Address - Country:US
Practice Address - Phone:845-647-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01554883Medicaid
NY01554883Medicaid
NYJW00F75310Medicare ID - Type Unspecified