MEDICARE: DR. BLAKE ELDEN WAYMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	12342	TX

General Provider Information

NPI Number	:	1205947033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE ELDEN WAYMAN

Provider Business Mailing Address
First Line	:	6024 UPPER VALLEY RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79932-4305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6901 HELEN OF TROY DRIVE, BLDG C
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79911-3043
Country	:	US
Telephone Number	:	915-581-8090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/15/2012

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