Provider Demographics
NPI:1174718654
Name:WILBY-WALLACE, MAXANA (ANP)
Entity type:Individual
Prefix:
First Name:MAXANA
Middle Name:
Last Name:WILBY-WALLACE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 1ST AVE
Mailing Address - Street 2:EMPLOYEES HEALTH SERVICE/METROPOLITAN HOSPITAL CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7404
Mailing Address - Country:US
Mailing Address - Phone:212-423-6384
Mailing Address - Fax:212-423-8602
Practice Address - Street 1:1901 1ST AVE
Practice Address - Street 2:EMPLOYEES HEALTH SERVICE/METROPOLITAN HOSPITAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7404
Practice Address - Country:US
Practice Address - Phone:212-423-6384
Practice Address - Fax:212-423-8602
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303569363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health