Provider Demographics
NPI:1215975669
Name:WOLBERT, JERRY (RN FNP)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:WOLBERT
Suffix:
Gender:M
Credentials:RN FNP
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Mailing Address - Street 1:45 TIEMANN PL
Mailing Address - Street 2:#2R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027
Mailing Address - Country:US
Mailing Address - Phone:212-387-7400
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:GOUVERNEUR MEDICAL STAFF OFFICE , R-1249
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2010-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF330202363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2E4561Medicare PIN