Provider Demographics
NPI:1023993748
Name:WALLICK, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WALLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-2711
Mailing Address - Country:US
Mailing Address - Phone:516-458-6811
Mailing Address - Fax:
Practice Address - Street 1:900 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2145
Practice Address - Country:US
Practice Address - Phone:516-256-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2072246367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered