Basic Information
| Provider Information | |||||||||
| NPI: | 1003259532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENGERTER | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, RPVI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5A MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453620075 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5A MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453620075 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 25MA10255100 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0129X | 276619-1 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.