Provider Demographics
NPI:1164580031
Name:WASHA, DAVID MARK (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:WASHA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 US HWY 16
Mailing Address - Street 2:
Mailing Address - City:LACROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601
Mailing Address - Country:US
Mailing Address - Phone:608-785-7746
Mailing Address - Fax:608-782-2938
Practice Address - Street 1:1415 US HWY 16
Practice Address - Street 2:
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-785-7746
Practice Address - Fax:608-782-2938
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2535111NS0005X
MN2813111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN279J7WAOtherBLUE CROSS BLUE SHIELD
WI391762498OtherFED TAX
WI391762498015OtherBLUE CROSS BLUE SHIELD
P00046865OtherRAILROAD MEDICARE
WI000070231Medicare UPIN
MN279J7WAOtherBLUE CROSS BLUE SHIELD
P00046865OtherRAILROAD MEDICARE