Provider Demographics
NPI:1932292174
Name:WASP, ERIC R (PA)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:R
Last Name:WASP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 BAINBRIDGE AVE
Mailing Address - Street 2:SUITE 300; LOWER LOBBY
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2490
Mailing Address - Country:US
Mailing Address - Phone:718-920-5525
Mailing Address - Fax:
Practice Address - Street 1:3400 BAINBRIDGE AVE
Practice Address - Street 2:SUITE 300; LOWER LOBBY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2490
Practice Address - Country:US
Practice Address - Phone:718-920-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant