Provider Demographics
NPI:1245239219
Name:WANNER, JAMES RUSSELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RUSSELL
Last Name:WANNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 ATKINS AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4913
Mailing Address - Country:US
Mailing Address - Phone:717-538-0161
Mailing Address - Fax:
Practice Address - Street 1:422 ATKINS AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-4913
Practice Address - Country:US
Practice Address - Phone:717-538-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS009042L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA054087Medicare ID - Type Unspecified