Provider Demographics
NPI:1992282339
Name:WILTSE, EDWIN MICHAEL NEIL (LAC)
Entity type:Individual
Prefix:
First Name:EDWIN MICHAEL
Middle Name:NEIL
Last Name:WILTSE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:WILTSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:43 E 10TH ST APT 6H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6106
Mailing Address - Country:US
Mailing Address - Phone:212-804-7267
Mailing Address - Fax:212-518-0578
Practice Address - Street 1:43 E 10TH ST APT 6H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6106
Practice Address - Country:US
Practice Address - Phone:212-804-7267
Practice Address - Fax:212-518-0578
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006308-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006308-1OtherLICENSE