Provider Demographics
NPI:1235762667
Name:WHEAGAR, EMMANUEL RANDOLPH
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:RANDOLPH
Last Name:WHEAGAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6248 LAKELAND AVE N STE 208
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-2989
Mailing Address - Country:US
Mailing Address - Phone:848-230-1286
Mailing Address - Fax:
Practice Address - Street 1:6248 LAKELAND AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-2986
Practice Address - Country:US
Practice Address - Phone:848-230-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJW32792257902702OtherDRIVER'S LICENSE