1700046190 NPI number — ELIZABETH LE WANNEBO MD

Table of content: ELIZABETH LE WANNEBO MD (NPI 1700046190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700046190 NPI number — ELIZABETH LE WANNEBO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANNEBO
Provider First Name:
ELIZABETH
Provider Middle Name:
LE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LE
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
NGOC
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700046190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 BOYDS SCHOOL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GETTYSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17325-8580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-327-0671
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 BOYDS SCHOOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GETTYSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17325-8580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-327-0671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2008

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: 207R00000X , with the licence number:  MD434557 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: MD434557 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 211210 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 018317200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2056156 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102170568 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120275 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 935776 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9928179 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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