Basic Information
Provider Information
NPI: 1003804360
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WRZESINSKI
FirstName: TAMARA
MiddleName: JENNIFER
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: GREEN
OtherFirstName: TAMARA
OtherMiddleName: J
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MD
OtherLastNameType: 1
Mailing Information
Address1: PO BOX 14890
Address2:  
City: ALBANY
State: NY
PostalCode: 122124890
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1092 MADISON AVE
Address2:  
City: ALBANY
State: NY
PostalCode: 122082248
CountryCode: US
TelephoneNumber: 5185252445
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/11/2005
LastUpdateDate: 10/08/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 10/08/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X260478NYY Allopathic & Osteopathic PhysiciansPediatrics 
208000000X043303CTN Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
00143303605CT MEDICAID


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