Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 016680-1 | NY |
NPI | 1003102096 |
---|---|
Provider Name | Jonathan P Wascak |
First Address | Hamburg, NY 14075-1724 |
Second Address | Hamburg, NY 14075-1724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2011 |
Last Update Date | 28/06/2011 |