Provider Demographics
NPI:1205819281
Name:FERNANDO, WANNAKUWATTE W (MD)
Entity Type:Individual
Prefix:
First Name:WANNAKUWATTE
Middle Name:W
Last Name:FERNANDO
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3271
Practice Address - Fax:508-856-5911
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76254207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3152634Medicaid
MAA21047Medicare PIN
MA3152634Medicaid
MAA2104702Medicare PIN
WVP00452227OtherRAILROAD MEDICARE
MAFE A21047Medicare ID - Type Unspecified
PA1017488140001Medicaid
MD411880400Medicaid
MA3152634Medicaid