Provider Demographics
NPI:1982877296
Name:IBRAHIM, WAGIH (RSA)
Entity type:Individual
Prefix:MR
First Name:WAGIH
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SAW MILL RIVER RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-1541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 SAW MILL RIVER RD
Practice Address - Street 2:SUITE 206
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-1541
Practice Address - Country:US
Practice Address - Phone:914-631-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant