Provider Demographics
NPI:1154312122
Name:WAMPLER, DUANE M (PA-C)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:M
Last Name:WAMPLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 DAY RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-4329
Mailing Address - Country:US
Mailing Address - Phone:574-204-7200
Mailing Address - Fax:574-252-0633
Practice Address - Street 1:1802 DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-4329
Practice Address - Country:US
Practice Address - Phone:574-204-7200
Practice Address - Fax:574-252-0633
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000266A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP77870Medicare UPIN
IN146470OOOOMedicare ID - Type Unspecified