Basic Information
| Provider Information | |||||||||
| NPI: | 1164095519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 CAMPBELL LN | ||||||||
| Address2: | |||||||||
| City: | EAST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117303622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318136137 | ||||||||
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| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
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| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 168875 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.