Healthcare Provider Details

I. General information

NPI: 1669717898
Provider Name (Legal Business Name): MR. WAYNE ANTHONY WASHINGTON II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MORGAN AVE N
MINNEAPOLIS MN
55414
US

IV. Provider business mailing address

1524 MORGAN AVE N
MINNEAPOLIS MN
55411-3014
US

V. Phone/Fax

Practice location:
  • Phone: 612-200-6233
  • Fax:
Mailing address:
  • Phone: 612-200-6233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: