Provider Demographics
NPI:1033178405
Name:LEEBAW, WAYNE FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:FREDERICK
Last Name:LEEBAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 YORK AVE S
Mailing Address - Street 2:SUITE 180
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5845
Mailing Address - Country:US
Mailing Address - Phone:952-927-7810
Mailing Address - Fax:952-927-6309
Practice Address - Street 1:7701 YORK AVE S
Practice Address - Street 2:SUITE 180
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5845
Practice Address - Country:US
Practice Address - Phone:952-927-7810
Practice Address - Fax:952-927-6309
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120263C626OtherUCARE
MN21002OtherAMERICA'S PPO
MN3317283OtherMEDICA CHOICE
MN410999025OtherTRICARE
MN656388100Medicaid
MN0256006OtherSELECT CARE
MN3300003OtherMEDICA PRIMARY
MNHP13803OtherHEALTH PARTNERS
MN53967LEOtherBLUE CROSS BLUE SHIELD
MN960540799004OtherPREFERRED ONE
MN104082OtherPATIENT CHOICE
MN3300003OtherMEDICA PRIMARY
MNHP13803OtherHEALTH PARTNERS
MN21002OtherAMERICA'S PPO