Provider Demographics
NPI:1528471687
Name:WAKSZUL, EPHRAIM (PA)
Entity type:Individual
Prefix:
First Name:EPHRAIM
Middle Name:
Last Name:WAKSZUL
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 1:19 WOODLAND ST STE 23
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2368
Mailing Address - Country:US
Mailing Address - Phone:860-522-2251
Mailing Address - Fax:
Practice Address - Street 1:19 WOODLAND ST STE 23
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2368
Practice Address - Country:US
Practice Address - Phone:860-522-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3330363AM0700X, 363A00000X
NJ25MP00336900363A00000X
NY23 017623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical