MEDICARE: PETERSON WAMBUU

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	172A00000X	Driver

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386334456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETERSON WAMBUU

Provider Business Mailing Address
First Line	:	2323 BENNETT AVE
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50310-6112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2323 BENNETT AVE
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50310-6112
Country	:	US
Telephone Number	:	515-344-3153
Fax Number	:

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

Provider Enumeration Date	:	05/11/2023
Last Update Date	:	05/11/2023

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Directions to “ PETERSON WAMBUU ” Practice Location

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