Healthcare Provider Details

I. General information

NPI: 1689609661
Provider Name (Legal Business Name): GREGORY K. WANNER DO, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

PO BOX 7529
NEWARK DE
19714-7529
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1840
  • Fax:
Mailing address:
  • Phone: 302-294-1468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00150600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT015368
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC2-0011617
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: