Healthcare Provider Details

I. General information

NPI: 1386476554
Provider Name (Legal Business Name): BENJAMIN WAHLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 GREEN BAY RD
NORTH CHICAGO IL
60064-3037
US

IV. Provider business mailing address

14912 SE 66TH ST
BELLEVUE WA
98006-5022
US

V. Phone/Fax

Practice location:
  • Phone: 206-390-0022
  • Fax:
Mailing address:
  • Phone: 206-390-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041549498
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP.AP.70132391-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: