1376596312 NPI number — WILLIAM M WANSA MD

Table of content: WILLIAM M WANSA MD (NPI 1376596312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376596312 NPI number — WILLIAM M WANSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANSA
Provider First Name:
WILLIAM
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376596312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85285-8247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-967-6500
Provider Business Mailing Address Fax Number:
480-967-6540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 PROSPECT PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-1943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-522-3722
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

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: 207P00000X , with the licence number:  ME0080374 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: G50191 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 259748900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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