Provider Demographics
NPI:1972796696
Name:WIESENTHAL, ADAM JASON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:JASON
Last Name:WIESENTHAL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:707 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2650
Mailing Address - Country:US
Mailing Address - Phone:845-333-7575
Mailing Address - Fax:845-333-3641
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-333-7575
Practice Address - Fax:845-333-3641
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012686363A00000X
CT002057363AS0400X
NY012686-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03315184Medicaid
NYA400007594Medicare PIN