Healthcare Provider Details

I. General information

NPI: 1982959391
Provider Name (Legal Business Name): TIMOTHY E WASANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 PLAZA DR SUITE 1100
WAUSAU WI
54401-4158
US

IV. Provider business mailing address

2720 PLAZA DR SUITE 1100
WAUSAU WI
54401-4158
US

V. Phone/Fax

Practice location:
  • Phone: 715-847-2472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4881-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: