MEDICARE: WAYNE ADAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	R1204660615	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A9943653	OTHER	CA	CALIFORNIA DRIVERS LICENSE

General Provider Information

NPI Number	:	1306215108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE ADAMS

Provider Business Mailing Address
First Line	:	1306 KANSAS ST
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4710
Country	:	US
Telephone Number	:	707-718-0147
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 KANSAS ST
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4710
Country	:	US
Telephone Number	:	707-718-0147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2015
Last Update Date	:	09/22/2015

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