Provider Demographics
NPI:1902997091
Name:WAXMAN, DENNIS (PA)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:WAXMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:CRMC PHYSICIAN SERVICES
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742-0421
Mailing Address - Country:US
Mailing Address - Phone:845-794-9864
Mailing Address - Fax:845-794-9868
Practice Address - Street 1:111 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:NY
Practice Address - Zip Code:12734-4315
Practice Address - Country:US
Practice Address - Phone:845-292-6630
Practice Address - Fax:845-794-9868
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01969891Medicaid
NY0F1911Medicare PIN
NYS68778Medicare UPIN