Provider Demographics
NPI:1073568218
Name:WAKHAM, MANCEL WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:MANCEL
Middle Name:WAYNE
Last Name:WAKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2497 S. ROANE ST.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748
Mailing Address - Country:US
Mailing Address - Phone:865-230-5698
Mailing Address - Fax:
Practice Address - Street 1:2497 S. ROANE ST.
Practice Address - Street 2:SUITE 110
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748
Practice Address - Country:US
Practice Address - Phone:865-230-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0140287OtherUNITED HEALTHCARE
P00114578OtherMEDICARE TRAVELERS
TNQ036092Medicaid
TN0101OtherJOHN DEERE HEALTHCARE
TN4091772OtherBLUE CROSS BLUE SHIELD
TN4091772OtherBLUE CROSS BLUE SHIELD
TN3725874Medicaid