1164610515 NPI number — MS. PATRICIA ANN WANZER-BURGESS R.PH

Table of content: MS. PATRICIA ANN WANZER-BURGESS R.PH (NPI 1164610515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164610515 NPI number — MS. PATRICIA ANN WANZER-BURGESS R.PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANZER-BURGESS
Provider First Name:
PATRICIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.PH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WANZER-BURGESS
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.PH
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164610515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2332 WHITE OWL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUITLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20746-1064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-736-8998
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79TH MED GROUP, MGMC 1050 WEST PERIMETER RD
Provider Second Line Business Practice Location Address:
ANDREWS AIR FORCE BASE
Provider Business Practice Location Address City Name:
ANDREWS AIR FORCE BASE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20762-6600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-857-4566
Provider Business Practice Location Address Fax Number:
240-857-4544
Provider Enumeration Date:
10/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  09536 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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