Provider Demographics
NPI:1912097015
Name:EVELYN, WANDA (NP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:EVELYN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-3924
Mailing Address - Fax:516-572-3631
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-3924
Practice Address - Fax:516-572-3631
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405157363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP65048Medicare UPIN