Provider Demographics
NPI:1093837460
Name:MINNIS-DYSON, WANDA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:RENEE
Last Name:MINNIS-DYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PENNSYLVANIA AVE SE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-4318
Mailing Address - Country:US
Mailing Address - Phone:202-575-4660
Mailing Address - Fax:202-547-7900
Practice Address - Street 1:650 PENNSYLVANIA AVE SE
Practice Address - Street 2:SUITE 250
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-4318
Practice Address - Country:US
Practice Address - Phone:202-575-4660
Practice Address - Fax:202-547-7900
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD19253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0491820Medicaid
DC52-2140839OtherTIN
DC0491820Medicaid