Healthcare Provider Details

I. General information

NPI: 1104568682
Provider Name (Legal Business Name): MICHAEL A WREASE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE WREASE BS

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E SCHUSTER AVE
EL PASO TX
79902-4659
US

IV. Provider business mailing address

12904 ALFREDO APODACA
EL PASO TX
79938-1000
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-8484
  • Fax:
Mailing address:
  • Phone: 478-220-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: