Provider Demographics
NPI:1174388680
Name:WINE, REBECA (PA)
Entity type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:WINE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 E LAWN DR
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6641
Mailing Address - Country:US
Mailing Address - Phone:914-318-5931
Mailing Address - Fax:
Practice Address - Street 1:535 W 110TH ST APT 1E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2021
Practice Address - Country:US
Practice Address - Phone:212-280-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
NY031585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant