Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | 17650 | NJ |
NPI | 1659592715 |
---|---|
Provider Name | Mr. Paul Edward Wry |
First Address | Rockaway, NJ 07866-4152 |
Second Address | Lafayette, NJ 07848-2214 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25MA01765000 | MEDICAL LICENSE (01) | NJ |