Provider Demographics
NPI:1548742166
Name:NOWICKI, WALTER ANTHONY
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:ANTHONY
Last Name:NOWICKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 FRONTIER LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-5520
Mailing Address - Country:US
Mailing Address - Phone:516-707-8002
Mailing Address - Fax:
Practice Address - Street 1:19 FRONTIER LN
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-5520
Practice Address - Country:US
Practice Address - Phone:516-707-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20467225700000X
NY6289171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist