Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 257433 | NY |
NPI | 1518181957 |
---|---|
Provider Name | Kim Gabrielle Wallenstein |
First Address | Liverpool, NY 13090-5010 |
Second Address | Syracuse, NY 13210-1603 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2007 |
Last Update Date | 06/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03254340 | (05) | NY |