Provider Demographics
NPI:1104102441
Name:WASIELEWSKI, NOAH JON (ATC)
Entity type:Individual
Prefix:DR
First Name:NOAH
Middle Name:JON
Last Name:WASIELEWSKI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 2ND ST
Mailing Address - Street 2:BLOOMSBURG UNIVERSITY
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1301
Mailing Address - Country:US
Mailing Address - Phone:570-389-4781
Mailing Address - Fax:
Practice Address - Street 1:400 E 2ND ST
Practice Address - Street 2:BLOOMSBURG UNIVERSITY
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1301
Practice Address - Country:US
Practice Address - Phone:570-389-4781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0013532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer