Provider Demographics
NPI:1255315628
Name:WAGENAAR, DEBORAH BANAZAK (DO)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:BANAZAK
Last Name:WAGENAAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:ANNE
Other - Last Name:BANAZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-353-3070
Mailing Address - Fax:517-884-1817
Practice Address - Street 1:909 WILSON RD RM B119
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6410
Practice Address - Country:US
Practice Address - Phone:517-353-3070
Practice Address - Fax:517-884-1817
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010085302084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1255315628Medicaid
MI3179331Medicaid
MI1255315628Medicaid
MI0C36166017Medicare ID - Type Unspecified