Healthcare Provider Details

I. General information

NPI: 1447201470
Provider Name (Legal Business Name): WAKEMAN AREA FAMILY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HYDE ST
WAKEMAN OH
44889-9301
US

IV. Provider business mailing address

24 HYDE ST
WAKEMAN OH
44889-9301
US

V. Phone/Fax

Practice location:
  • Phone: 440-839-2226
  • Fax: 440-839-1339
Mailing address:
  • Phone: 440-839-2226
  • Fax: 440-839-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50000956
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP08465
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35062083
License Number StateOH

VIII. Authorized Official

Name: LAURA TANIGAWA
Title or Position: OFFICE MANAGER
Credential:
Phone: 440-839-2226