Provider Demographics
NPI:1053370148
Name:WAKSMONSKI, TIMOTHY G
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:G
Last Name:WAKSMONSKI
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 1:1538 ROUTE 12
Mailing Address - Street 2:UNIT 7
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1845
Mailing Address - Country:US
Mailing Address - Phone:860-444-8408
Mailing Address - Fax:860-444-8413
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-8100
Practice Address - Country:US
Practice Address - Phone:860-444-8408
Practice Address - Fax:860-444-8413
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24720000X146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic