Healthcare Provider Details

I. General information

NPI: 1114619400
Provider Name (Legal Business Name): ROMARIC WAGUIA KOUAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 24TH ST S
WISCONSIN RAPIDS WI
54494-1908
US

IV. Provider business mailing address

PO BOX 1363
CARY NC
27512-1363
US

V. Phone/Fax

Practice location:
  • Phone: 715-424-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number82235
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01100165A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: